Frost, Susan ! s
('i(ic Ccnicl.cry & C:re:nlatoriulll
Ou;tkcr Road
Ouccusbury, NY 1280/1,
(.5 18) 7 or (,5I8) 711.5-411,76
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No(c; The C;rcm.t(ion I.oh shall Inc retained iu Ilic PCI•In;Ulcll( file of (lic CretwOory
.S 5
NYS Department of State
Authorization for Cremation and Disposition °i 10n Or tWM
One Commerce Plaza,88 V 9 AlbaM,�A12231
(618)474-6226
www.dos.state.ny.us
This Authorization Form must be completed and signed prior to delivery of remalns for cremation.
Date: A
Number. 35
Crematory Name:
Address:
Phone:--1.. �S�,S= Sr?�
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is carried out by placing the remains of the deceased and tt►e 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 everytt�tng 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
�ecogniizable as skeletal tissue.
na�NwG OF CONTAINER
The crematory may only open the container holding the un-cremated human remains in limited circumstances, such
nsure that no material is enclosed which might injure employees or
as to confirm the identity of the deceased or to e
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.
ipENTIFICATtON OF DECEASED
Name of Deceased: Sl,���Ji�s`7' Marital Status: oQAlf D
Last Known Address:
Place of Death: +�.
4tiS UGC- ��b o I
Sex: ❑M IXF Age: _ DOB: Date of Death: 7 bi Estimated Weight:_
Description of casket(container in which remains will be delivered:
I
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PERSON IN CONTROL OF QISPOSITION
(Person(s)in control of disposition, L 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.
-OR-
r e no knowied a that the deceased executed a written instrument pursuant to Public Health Law
jai; U 1 o hav 9
to-ion 4201 or a will containing directions for the disposition of his or her remains and (Continued next page)
�f
'�ofDeoee�d Page 1 Of 3
DOS-169&f-t (Rev.01M0)
i
ave the right
I am/due are the person(s)having priority under Public Health Law section4201
42e eased a as follows:to authorize
cremation of the remains of the deceased. My/Our relationship
(Insert from the list below)
Number. Description: jS Soo �
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;
6.A surviving sibling eighteen years of age or older,
6.A lawfully appointed guardian;
T.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§4201(7);
10.A chief fiscal officer of a county or a public administrator appointed pursuant to the Surrogate's Court
Procedure Act;
half of the deceased and who has executed a written statement
10a.Any other person who is acting on be
pursuant to Public Health Law§4201(7).
(initial AU THREE of the following)
-ILIbIMe 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 I
crem personnel.
'j t Me hereby affirm that instructions have been given to(funeral directorname) / 1MA�/�
regarding the removal of any personal property or other thing of Vplue which any person signing below or any'family
not
member of the deceased wishes to preserve. (sematoryna►rre) zeka di r�fl7ilTa�c�1'L_
responsible for removal of personal items from the container or from the remains of the deceased. Wersonal items
left in the container or with the remains will be destroyed by the cremation process and cannot be retrieved
after cremation.
[Me hereby authorize(a natory name) /'� Cremate the
remains of the deceased.
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name: ��,41 ki ., /=
, --� Ph ld"? 3�?
Address:!' �,%Q Q-CA1 Cr,L£as r S �y / one:S
The cremated remains of deceased will be disposed of as follows:
If for any reason tAe person named above ddes not take possession of the cremated remains,
(crematory nama) J4e V1 eaJ C R f t 1n a t is authorized to give possession of the remains to
(funeral home name)
by delivery in person or by registered mail.
Nr2rs �---
DOS-18WM (Rev.01/10) Name of Oeceesed Page 2 of
i
(Ujd*W he following)
I/We un5lrstand that if the remains are not claimed within 120 days of cremation,
(arematoryname) �'.� !7' may dispose of the remains in an irretrievable manner,
such as by scattering.
CREMATION CONTAINER/URN
(Initial ONE of the following)
An um to be used as a container for the cremated remains has been purchased from
and is described as follows:
I/We understand that if the um is too small to hold the entire cremated remains, an additional rigid container may be
used for delivery.
-OR,-
L/�L.- An u s not yet been purchased. I/We understand that if no um is purchased or otherwise provided
(crematory kjrtza >>Q __ will place the cremated remains in a rigid temporary
container for delivery.
This Authorization Form was provid (funeral director name) 2&'�ke-6w
executed at(funeral hone name) I WQ—4 '
(funeral Home address) A3 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)identified below is/are 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 f day of f 20
Typed or Printed Name signature
Address
Typed or Printed Name signature
Address
Typed or Printed Name Signature
I
Address
I
WITNESS:
T
�,e
Funeral Director Typed or Printed Name
Funeral rector signature
=M?
Regiarstion N mber j
I
ooS-18Wf-1 (Rev.01/10) Name of Deceased Page 3 of 3 j
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