Yole, Patrick PHIC N/icw Ccnict.cry & Cre:nialor-iuIII
Quakcr Road
Ouccnsbury, NY 1280/1.
(.518) 7/15-4/1-77 or (518) 74,5-11-476'
Flutcral 1-ioltic - ----.-.- Q�ti --
r1�1���F..L,,.(//�� ! Ralucslal Rclur n 'I
Mime
No. L3
Dale of Cremation-__i_I�L�._..--"1 in1c SIarlccl_.---g_' 'iluc Compiciccl__-___-�D-��
N'tced in Hold:
Phccd in Rch-igc:ralion:
Placed in HMO: ___.----_-__— 60
'I'ypc or Container ---------m t��c-� ..-- -- —l z'►�- -_c"�f - ---t— �' -- ---
Remarks
Main b-9d - — Vi(>vC------------t�-�°
P%cc or neat,'
lslintatccl of, Remain~ and Cout,iincr-----------
Date c T'Iltc RCinalns arrival al Crclualory113U 3�Zt7
Mum of* Funeral Director or Rco-islcred Rcsicicnl Dclivcring Rctnains.---.-.---�{��---���(�
Dctailcd reason 1,01. delay il,remain" wcrc c1*c111,0cd more (lien 'IR hours Iron) link ol'.u:ccl>tal
delivery
-------------------------------------------------------------------------- ------
I
Retort Number in which Reivaius Wcre crcui;ilccl____.-____--
------.f.r _ ---- -- —
I
Notc:The Cremation I.o�; shall Inc rclained iu llic Pernmilelll l"ilc of,Ilic C;rcntalory
I
` 7
New York State
DeparUnent of Stet!
NEMf Yt�RK QIYson 4f gN/1grpN OF CRIES
Ch�e CwWrowce Plaza
CemetCemeteries g At".g was NY 1 n Avenue
eries NY 2231-0001
Telephone:t61%4W6226
www.dorary.gov
AUthadt t fair i".i 9=diln and DWpmfoo n
This Auaxw raVan Fan,must be completed and*!Mead prkw to delivery of remains for crenudion.
Date: T., 2, 20 1 —Number. j
Cmnatory Name: "n�' C.lr Q wt.Ce..ty✓s'iAtia
Address: � ��n S E9zc>r► Phcxw: 1�' ... u�-- �f�7�
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation Is carried out by placing the remains of the dooessed aexl the owftkw holding the rem Into a crwmdan+ch n1W where
It"are su* d Ut and henna.
heat a The held WW Same WIN 10Oitrerals and erring erxaapt bone andrraepf,
witch we all that will be left after ea*motion.
Following the cematory wiN take reasonable eftofft to remove all of fe remotes and other material from the cremate,
chamber,but some mi*M dust and rrrsid o will likely be left bentari,d. The crematory will separate incidental and foreign material from
the remains and the incidental and foreign material Will be of as required by law. The cremated re meft will be mechanically
pulverized k,to small places and placed into a designated container or tan. +Cr+srn@W ternalne generally raft are pulverised unto no
single fragnmd Is recowtizablo as skeletal tlssu6.
MUM Of OWMER,
The,awratwy may only opan to holding the human remains In limited circumstances.such as to Confirm the
Wentity of the decessed or to wan that no material is onclosW whit,ff4d at damage the asmalory property 1f
human renalrne are dollwored Ina which Is not sine for croauldon such as oaremovital or canal caSkail,the
crremacq will require Est tin remains be mewed hdo a suil4ble ssatdalrW before it accept*tat remains. The opening of a
container or the or removal of rremakvs will be conducted before a wifives and w8 be dwte in privacy,WWI dignity and respect.
i
IDZbMMATION!QFQ&Qfi4W I
Name o f r 'W _ _Meru Status: ----_ _
Last Known Address; r" �✓i e S '"` ��`� s C 1P XT1ed�
I
Place of Death• }
Seac: M ,F Alga: of Death: Estimated W*ht:
Sext.: IM qF Age.
Description of a uketA€ontriner in vdtknt,r II
m 7"
PMMM III ramm RE
r gral to ON"Of dfalsatrWn. t a"1400"no
4 1 amtWe are the designated agent of the deceased ckaigrn W 4n a win or written instrument executed pursuant to Public
Health Law Section 42D1.
i
two have no knowledge that the deceased executed a written Webument pursuant to Pew Health Law Shinn 4201 or a j
will containing directions for the disposition of his or her remains and Uwo are the porson(s)having priority under Pt6k Herald,Law
Section 4201 and have the fight to a of the remains
MlylOur ntalbnship for Me deceased Is as
foil m:
DOS»1804(Rev.MIS) Page 1 of 3
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C0 TO"
U MER'S DESIGNATION OF NTIONS
Z,
Name of ased: • 0.
Cremation:
Manner of Dis sition of Cremains:
Burial at: f❑M eturn to:
❑ Entombment Other:
Disposition of Cremains ated by:
^A
V '71
466i) (giP)
z
MOW
"Cremains which shall not have been aimed 120 days from the date of cremation may be
disposed of by this firm,in the followi manner of dis ition:
(Name ofFoaaW nimckwt)rdrrtaker} (SISMMM of F I U"em imeftworWWOUlkal)
TO BE COMPLETED FOLL WING CREMATION
RECEI
CREMAINS E I'VED:
Print Name
sirwurt of Paulo
DW ENameofPeaxonMWd"¢tiw"itim)
w t
Authorizadon for Cremation and L31f�
(insert from the fist below)
Number. . Dwaiption:
1. A person designated in vM"pub to Public Health Law Section 4201(3�
2. The survhing$Pause,
2a. The surviv ft domestic partner,
3. Any su*ft child eghteen Years of age or older,
4. A surviving parent;
5. A survirring sibWV eighteen years of age or olds
6. A lawfully appointed guardian,
T. Any persons)eighteen yews of age or older entitled to share in titre estate and who Ware closest in relationship to the deceased,
4. A duty appointed fiduciary of the estate,
9. A dose friend or rWStW$who has executed a written staternent idol to Public Health Law Section 4201(7):
10. A chief fiscal ofllcer of a county or a pubac adman' to the Surropte's Court Procedure Ad,
10a. Any odor person who Is ad"on behalf of the deceased and who has executed a written statement pwvuwA to Public Wealth
Law Sections 4201(T).
Oft ALL THREE of the foflowhV)
,_j.k,)Me hereby affirm tha4 the body of the deceased does rot contain a befty,bettexy Pedt.Power 0e9.radioactNS WAPIS"L
or radioactive device and that any such materials were removed p►1a'to the execution of this Arrawrlxattan Form. Failure to remove
these items Prior to emm**m May result In harm to#wt cremat+ary and crematory pomnnel.
-J,A, lnroe affirm that instructions have been given to ! I"7rJ
w--
regarcltrrg the removal of any personal property or other fift of value which any person Wong below or any family ember of the
fj&J
deceased wishes 14
is not responsible for the container of Personal items kv the contar or from tlo remains of the deceased. Personal?Items ieit in the
container or with the rermains will be destroyed by the cremation process and cannot be retrieved after crematias.
Plilte hereby authodme •t i C Vie,a) il"U
to cremste the remains of the deceased.
FINAL DISPOSMQU
The person to receive the cremated remains of the deceased from the crematory is:
Name' ,
Address: Ph
xrhe cremated of willbe disposed of as follows: tQu /' w f .
ba"i h ���G� Lam✓IC., t.,PJWt.—
koci �l
if for any reason 717t
earned abo`rs does not take posaesslors of the cremated tenair►s,
is authorized to give possession of
the remains to by delhvery
rr
000"M Now
In person or by r mafi.
ewm.oro«--O
DOS-IM4(Rev.08I15) Page 2 of 3
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Authorization for Cremation and Disp
f�ta t me"owing)
11We understand that if the remains are not claimed wilt»n 120 mays of"Ma
twn,
an irretriev"manner,such as by scattering. ram.arc r r ' ` of the rerrrains in
�` fttt�i'oNE of�totlowing}
An um to be used as a Container for the cremaled remains has been Purchased from
and is described as Bows:
I/We understand that H the urn is too small to hold the entire OWnsted remains,an arddfUonai rind WrM*w may be used for delivery.
,PR-
An urn is not yet purdissed. UWe understand that if no urn is WdutW or othrwise proyided
wit Place the txemated remains in
a rigid temporary Ones for delivery.
This A ffon FOM was Provided by » C J . i
,,w was executed at
r.roverAdftso
and is signed by the funeral director as witness to its execution.
11We have received a completed cOPY of ties AuttrosfzatfonThe Form.
#w person(a)in o0nbVI fa the u(s)i b*I wr Mare ofdispoai�n,who by signing this Aluft Edon Fo
�s of the Intormatlo>n C"binsd In this Autfro&adon Fare and autirurixa(s)the re sttest(s)
Signed thb. day,of_ �u.». fQrogoinp.
t
sue' erne Zl w a L/ /7/
WITNESS,
t��r,ul ,.r39aedwpArMay r ��,�(„�.
,Pcu- ty i-c k. VO t-
s� }
r d'w'aa'SpaR;�at
DOS-1$Wf(Rev.08/15)
Page 3 of 3
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kuthodnition for Cremation and Dis
(am
rM WOW")
1 Uwe understand that if the remains are not claimed within 120 data of aematah,
,may dispose of t o remains in
040•o+C--AWW
an Irretrievable manner,such as by scattering.
reREMATIQU CQtff 1MAN
aaO ONE ofrtt a hhffowhV)
An um to be used as a container for the cremated remains has been purchased from
and is described as follows•
Me understand that N the urn is too small to told the entire rx+ natal remains,an additional rigid container may be used for delivery.
Fi
An urn is not yet purdmad. UWe a d, rs that N no u m Is pun�owA or odwwl"provided
i�wo will piece the cremated remains in
Oft of d�re�rorp�
a rigid temporary container for delivery.
This AuthIr Form was`PwAded by eD�t } ! � was executed at
and is signed by the funeral director as witrwess to its execution.
I/We have received a completed copy of this Audwoftadon Form,
The person(s)IderMled below Mans the persons)In control of disposition,who by signing this Authorkedon Form,att"t(s)
to the accuracy uracy srul complalenass of tM kAwmadw contained in Wo Aadwk&don Faro►sued Mhorb*s)the brogoing.
Signed tilts day of..I a,,V)e.c-cW") 20
t q
r''*d"' YA- I
, ,
TWO-d of
I
WITH
jAo uhu.awTV#W*tPelalyd
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DOS-IOWf(Rev.08115) Page 3 of 3 j
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Authorization for Cremation and Dhgw on
(Insert from the fiat below)
Number._,�_ Description:
1. A person desi0naled in writing pursuant to Public Health Law Section 4201(3X
2. The surviving spouse;
2a. The surviving domestic partner,
3. Any surviving cad eighteen years of age or older;
4. A surviving pares
5. A surviving sung eighteen years of age or older;
6. A lawfully appointed ;
7. Any person(s)eighteen years of age or alder entitled to share in the estate and who Mare closest In relationship to the ;
8. A duly appointed fiduciary of the estate:
9. A close friend or relative who has executed a written stoMment pursuant to Public Health Law Section 4201(7
10. A chief fiscal~of a county or a public administrator appointed Pursuant to the SurrogaWs Daunt Procedure Act
10a. Any other person who is acting on behalf of the deceased and who has executed a written statement pursuant to Pubes Health
Law Section 4201(7).
([ ALL THREE of fie togowirrg)
Wire hereby adirm that the body of the deceased does trot contain a bit battery pack.power colt,radioactive
or radioactive device and that any such materials were removed prior to the execution of this Audiorkedon form. Fallurs to remove
these items prior to cremation may result In harm to the crematory and crematory poriipnnol.
,04fw
I/We affirm that instructions have been given to
regarding the removal of any personal property or other thing of value which any person suing below or any f w*y member of the
deceased wishes to
Is rust responsible for the removal of personal Items from the cx0rth*W or from the rarnains of the deceased. Personal items left In the
container or with the reinsins will be destroyed by do crwnatilon process and cannot be re trlayM after cre rtstiOn.
UWe hereby authofte mow
to cremate the rentains of the daeeesud.
FINAL OISPOSMOM
The person I ad to receive the cremated remains of the deceased from the crematory Is:
Name•
Address' )y��
cremated of will be of as follows:
�Gt1t,i�
If for any reason the person named above does not take possession of the arernated remains,
t Is authartred to give possession of
the remains to by deliverycr�•+•+a+tarn. .)
in person,or by registered mail.
ova"ao.o..�.up
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