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New York State
Department of State
NEW YORK D'v'S�On Of DIVISION OF CEMETERIES
STATE OF One Commerce Plaza
OPPORTUNITY. Cemeteries 99 Washington Avenue
Albany,NY 12 2 31-00 01
Telephone:(518)474-6226
www.dos.ny.gov
Authorization for Cremation and Disposition
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date: 01/04/2019 Number: Zg
Crematory Name: Pine View Crematorium
Address: 51 Quaker Road, Queensbury, NY 12804 Phone: (518) 745-4477
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 urn. Cremated remains generally are pulverized until no
single fragment is recognizable as skeletal tissue.
OPENING OF THE 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 the crematory property. If
human remains are delivered in a container which is not suitable for cremation such as 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:John Reilly Breen Marital Status: Married
Last Known Address: 9 Lynnfield Drive, Queensbury, NY 12804
Place of Death: Slate Valley Center For Rehab And Nursing , 10421 State Route 40, Granville, NY 12832
Sex: ®M OF Age: 87 DOB: 11/24/1931 Date of Death: 01/02/2019 Estimated Weight:
Description of casket/container in which remains will be delivered.
Matthews— Eventide Wood Casket
PERSON IN CONTROL OF DISPOSITION
(Person(s)in control of disposition, initial ONE of the following)
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.
l 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 I/we are the person(s)having priority under Public Health Law
Section 4201 and have the right to authorize cremation of the remains of the deceased. My/Our relationship to the deceased is as
follows:
John Reilly Breen
(Name of Deceased)
DOS-1898-f(Rev. 08/15) Page 1 of 3
Authorization for Cremation and Disposition
(Insert from the list below)
Number: 2 Description: Spouse
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;
8. A duly appointed fiduciary of the estate;
9. A close friend or relative who has executed a written statement pursuant to Public Health Law Section 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 Section 4201(7).
(Ini a L THREE of the following)
iF Me 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 harm to the crematory and crematory personnel.
rc L I/We affirm that instructions have been given to Wendy M. Bulich
(Funeral Drectar Name)
regarding the removal of any personal property or other thing of value which any person signing below or any family member of the
deceased wishes to preserve. Pine View Crematorium
(Cremetary Na—)
is not responsible for the removal of personal items from the container or from the remains of the deceased. Personal items left in the
container or with the remains will be destroyed by the cremation process and cannot be retrieved after cremation.
IMe hereby authorize Pine View Crematorium
(Crematory Name)
to cremate the remains of the deceased.
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name: Singleton Sullivan Potter Funeral Home
Address: 407 Bay Road, Queensbury, NY 12804 Phone: (518) 793-4459
The cremated remains of deceased will be disposed of as follows:
Return to family
If for any reason the person named above does not take possession of the cremated remains,
Pine View Crematorium is authorized to give possession of
(Crematary Name)
the remains to Singleton Sullivan Potter Funeral Home by delivery
(Funeral Home Name)
in person or by registered mail.
John Reilly Breen
(Name of Deceased)
DOS-1898-f(Rev. 08/15) Page 2 of 3
R
Authorization for Cremation and Disposition
(initial the following)
Me understand that if the remains are not claimed within 120 days of cremation,
Pine View Crematorium may dispose of the remains in
(Name or Crematory)
an irretrievable manner, such as by scattering.
CREMATION CONTAINER/URN
(Initial ONE of the following)
An urn to be used as a container for the cremated remains has been purchased from
and is described as follows:
Me understand that if the urn is too small to hold the entire cremated remains, an additional rigid container may be used for delivery.
-OR-
RAn urn is not yet purchased. Me understand that if no urn is purchased or otherwise provided
Pine View Crematorium will place the cremated remains in
(Name or Crematory)
a rigid temporary container for delivery.
This Authorization Form was provided by Wendy M. Bulich was executed at
(Funeral Diector Name)
Singleton Sullivan Potter Funeral Home
(Funeral Home Name)
407 Bay Road, Queensbury, NY 12804
(Funeral Home Address)
and is signed by the funeral director as witness to its execution.
INNe have received a completed copy of this Authorization Form.
The person(s) identified below islare the person(s) in control of disposition,who by signing this Authorization Form,attest(s)
to the accuracy and completeness of the information contained in this Authorization Form and authorize(s)the foregoing.
Signed this 4th day of January ,20 19
Frances Breen
Typed or Printed Name Signature
82 Queensbury Ave., Queensbury, NY 12804-
Address
Typed or Printed Name Signature
Address
Typed or Printed Name Signature
Address
WITNESS: n
Wendy M. Bulich
(Funeral Director Typed or Printed Name) (Funeral Director S'na re)
10441
(Registration Number)
John Reilly Breen
(Name of Deceased)
DOS-1898-f(Rev. 08/15) Page 3 of 3