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Joly, Sheila Pine Vic:'vv Ccliietery & Cl-cmat-oriurrl QW1kcr Road Queensbury, NY 12804 (518) 745-4477 or (518) 74,5-44-76 Funcral 1-1onlc Rc<luest.e:d Return '1"ivae s Nantc--------S�LIS_-�� ----------- --- - _Case No ....__ ---------��_---- _ . (� ---_.--- Date of Cremalion__-- 11 1il 15--_ [inu Stu lccl-- I_�o�' Time Comple(e<l._ Placed in 1-IUI(I: -------- - Placed in Refrigeration: Placed in Rctol't: Type of Container Remarks Main Move q�., ----------------------------- -- - - -- -- - - /.SS� Z:Z t' Place of Death------_--�Jbg�,�_____- � Estimated Weight.of Remains an(1 Conh(incr- 10 Datc V Timc Remains arrive(l al. Name of runcr�tl Director or Rcoistercd Resident. Delivering Ren►ains__ Delailed rc:ison for delay if re luains were creivat.ed more (lean 4.8 Fours from tiiiie of accepl:cd delivery -------------------------------------- --------------- Retort Number in which RClnallls wel-c Note:'['Iie Crcluation l.og shall be rclaine(I in lllc 1'crnlancut file of the Crclnatory PIPS Deparbnent of state Authorization for Cremation and Disposition Div ofCOffwteift One Commerce Plaza,99 was*Oon Avenue Albany.W 12231 (518)474-6226 www.dos.atate.ny.us This Auam*ation Form must be completed and signed prior to de&W of remains for cremation. te: /S— / NuNumberDa Crematory Name: iU�rJ Address: �.c�s cCQ ,bf7vhone;� ? � 7 yT T CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS. Cremation is carried out by placing the remains of the deceased and the container holding the remains into a cremation chamber where they are subjected to intense heat and flame.The heat and flame will incinerate and consume everything except bone and metal,which are all that will be left after cremation. Following cremation,the crematory will take reasonable efforts to remove all of the remains and other material from the cremation chamber, but some minimal dust and residue will likely be left behind.The crematory will separate incidental and foreign material from the remains and the incidental and foreign material will be disposed of as required by law.The cremated remains will be mechanically pulverized into small pieces and placed into a designated container or um. Cremated remains generally are pulverized until no single fragment is recognizable as skeletal tissue. OPENING OF CONTAINER The crematory may only open the container holding the un-cremated human remains in limited circumstances, such as to confirm the identity of the deceased or to ensure that no material is enclosed which might injure employees or damage crematory property. if human remains are delivered in a container which is not suitable for cremation such as a ceremonial or rental casket,the crematory will require that the remains be moved into a suitable container before it accepts the remains.The opening of a container or the transfer or removal of remains will be conducted before a witness and will be done in privacy,with dignity and respect, IDENTIFICATION OF DECEASED Name of Deceased: d c- Marital Status: Q t(1(J P—L C- Last Known Address: Place of Death: $0 Sex: ❑M Age:Ls-:!DOB: �.� /F Date of Death: % Estimated Weight:—) Description of casket/container in which remains will be delivered: &4J�Ll___e 0, '7'/9-c A.� t It !tu W& J LN PERSON IN CONTROL OF DISPOSITION aloin control of disposition, initial ONE of the following) nlsl I am/We are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public Health Law section 4201. -OR- I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law section 4201 or a will containing directions for the disposition of his or her remains and ( nued news) DOS-1898-f-1 (Rev.01/10) Nine of Deceased Page 1 of 3 I am/we are the person(s)having priority under Public Health Law section 4201 and have the right to authorize cremtrition of the remains of the deceased. My/Our relationship to the deceased is as follows: (Insert from the list below) Number: 3 Description: S o p 1.A person designated in writing pursuant to Public Health Law section 4201(3); 2.The surviving spouse; 2a.The surviving domestic partner, 3.Any surviving child eighteen years of age or older, 4.A surviving parent; 5.A surviving sibling eighteen years of age or older, 6.A lawfully appointed guardian; 7.Any person(s) eighteen years of age or older entitled to share in the estate and who is/are closest in relationship to the deceased; B.A duly appointed fiduciary of the estate; 9.A close friend or relative who has executed a written statement pursuant to Public Health Law§4201(7); 10.A chief fiscal officer of a county or a public administrator appointed pursuant to the Surrogate's Court Procedure Act; 10a.Any other person who is acting on behalf of the deceased and who has executed a written statement pursuant to Public Health Law§4201(7). ALL THREE of the following) IMe hereby affirm that the body of the deceased does not contain a battery, battery pack, power cell, radioactive implant,or radioactive device and that any such materials were removed prior to the execution of this Authorization Form. Failure to remove these items prior to cremation may result in ha to the crematory and crematory personnel. J11 I/We hereby affirm that instructions have been given to(Nne w*odorneme) regarding the removal of any personal property or other thing of mplue which any person signing below or any family member of the deceased wishes to preserve. (awwwy name) e Q ett is not responsible for removal of personal items from the container or from the remains of the deceased. ersonai items left in the container or with the remains will be destroyed by the cremation process and cannot be retrieved a�cremation. _�lMe hereby authorize(asmafory nW") ! � to cremate the remains of the deceased. FINAL D131!OS1TION •• The perso a to ive the cremated remains of the deceased from the crematory is: Name: Address: The cremated remains of deceased will be disposed of as follows: 4t, f—A-t-1 c� If for any reason person named abov does not take possession of the cremated remains, (a,,18f„y„WW) r��mmCrltEoJ8e7/Jy' ,�Leg is authorized to give possession of the remains to (rune w home name) by delivery in Or by registered mail. a \-J d` DOS-18W44 (Rev.01110) Name of Deceased Page 2 of 3 the foNowing) Me andeotand that if the rema�'�are not claimed in 120 days of cremation, (« ►rn � O� CZ J ��`t may dispose of the remains in an irretrievable manner, such as by scattering. . QREW"ON CONTAINERIURN (h"ONE of the foNowing). An um to be used as a container for the cremated remains has been purchased from and is described as follows- UWe understand that if the um is too small to hold the entire cremated remains,an additional rigid container may be used for delivery. -OR- 6 An ums not yet been u ased. IMte understand that if no um is purchased or otherwise provided {aematary name) L�(iLcJz'£� �� wili place the cremated remains Ina rigid temporary container for delivery. This Authorization Form was prov' was executed at mmopi hom name} , ( a&VMil eAs 0414CS and Is signed by the funeral director as witness to its execution. I/We have received a completed copy of this Authorization Form. The person(s)identiRed below is/are the person(s)in control of disposition,who by signing this Authorization Fonn,attests)to the accuracy and completeness of the information contained in this Authorization Form and authorize(*)the foregoing. S")Signed this day of 20� Typed or Prhtod Name Typed or PdnfW Name m Address TWO or Printed Nerve � Addlen WITNESS/ Fu or PrhHed-AWM Di►0doi RegistridW Numhw DOS-1888-N (Rev.01M0) Name of Deceased Page of 3