Beagle, Chester III �O
1'inu Vic:c�' C:cntetcr)' & Crcil�;ctc>riuitt
Ou�tkcr lZo;ul
Quccusbui y, NY 1 280/1•
(5 18) 7/1-5-4/1.77 c>r 018) 7/1-5-4/1-76
Rcctucs(ccl Rcturn '1•iinc �`t
1);ilc ofCrcnuttioii ,- fk __.._-..T1111c SI;ulcd A1l 1-1111c Complctccl__- 90 �h
Phcecl ill Hold: -._._--
�
I'I:u:ccl iu
ITIcccl in Rctort: _ .3.0
Type 4 Container --C�.�J b..r1 "W'a' - h _...1 ., �..f--- C�, t ��--uoJ, ,,. pL
i
Remarks
—30
Pl;wc or I)catll---.v-?
Igo lhr
l'sun1at.ccl \A/c4;1tl ol- IZcitr,uns ;utcl (;oul;unc ----
I
l);tic Time Rcivaucs ;u n�'ccl ;il C;rciiialc>r)'- c� -
�' I
Nantc ol' Funeral Director or Rct;islcrccl Rcsicicnl Dclivcrinz 11cmairts.___l.`��
1)cuiilecl reason I�or delay il� reni;tii�s wciC c�enciiccl nioic �li;iii �If� limns Irony tuiic oI ;u:ccl�tc�l
delivery
tc
Rctort NUInbcr in vliIclI IZc11liU11> Wcic CIclll;IIccl �r°"---.-�"____—. 1
Nolc: The U-c•.ination l.og s1mil Inc rctaiuccl ni Ilic PCrlll;lncllt File of the Cremator)'
i
I
i
I
' 1 New p rk State
Dell artmen- f State
NEWYORK Division of DIVISION OFCEM ERIES
STATE OF O e Comm ce Plaza
OPPORTUNITY. Cemeteries 99 ashingt Avenue
Alt any,NY 1 31-0001
Telep.one:(518 746226
www.d s.ny.gov
Authorization for Cremation and Disposition ° +
i,
This Authorization Form must be completed and signed prior to delivery of remains for cremati n.
4-(� 3 te
Date: Number:
l'
Crematory Name:
Address: (:401lu, toC-. , (� Lo.,SI,.ru .v,-)`i t-uol Phone: 7VS`g4'1
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 crematioh chamb where
they are subjected to intense heat and flame. The heat and flame will incinerate and consume everything except Pone anc 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 I ie mechanically
pulverized into small pieces and placed into a designated container or urn. Cremated remains generally are pulverized until' o
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 a to confirf the
identity of the deceased or to ensure that no material is enclosed which might injure employees or damage the crematory prope y. If
human remains are delivered in a container which is not suitable for cremation such as ceremonial or rental c sket,th'
crematory will require that the remains be moved into a suitable container before it accepts the remains. The pening c a
container or the transfer or removal of remains will be conducted before a witness and will be done in privacy,with dig ity and raspect.
A
IDENTIFICATION OF DECEASED cc�� --{{
Name of Deceased:�Qrli �" JAG (� Marital Status: Q1
Last Known Address: 9&Mcin St.A u f-�•(/ 'U� ��3
Place of Death: III
Sex: IM M ❑ F Age: S2. DOB: 1 I LZ' v` Date of Death: i 0 7.01 a _ Estimated eight: J1811�5
Description of casket/container in which remains will be delivered.
F
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 pur uant to f ublic
Health Law Section 4201.
-OR- J
' I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law ection 4,e 01 or a
will containing directions for the disposition of his or her remains and I/we are the person(s)having priority under Publi Health Law
Section 4201 and have the right to authorize cremation of the remains of the deceased. My/Our relationship to the ceasedis as
follows:
i
(Nam of Deceased) i
I
I
DOS-1898-f(Rev.08/15) Pag i 1 of 3
I{
I
�I
i
{G
4W I
Authorization for Cremation and Disposition *_
N
(Insert from the list below)
Number:3— Description: A",4•
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 relationshi 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 ProcedureAct;
10a. Any other person who is acting on behalf of the deceased and who has executed a written statement pursuant t Public ealth
Law Section 4201(7).
(Initial ALL THREE of the following)
G I/We hereby affirm that the body of the deceased does not contain a battery, battery pack,power cell, radi active implant,
or radioactive device and that any such materials were removed prior to the execution of this Authorization Form. Fa lure to remove
i
these items prior to cremation may result in harm to the crematory and crematory personnel.
r
l�. I/We affirm that instructions have been given to a( c s 1
(Funeral Director Name)
regarding the removal of any personal property
ror'other thing of value which any person signing below or any family m mber of he
deceased wishes to preserve. t U$j"JC ryly,)"r i`- "'
(Crematory Name)
is not responsible for the removal of personal items from the container or from the remains of the deceased. Personal items le in the
container or with the remains will be destroyed by the cremation process and cannot be retrieved after cremat on. j I
I
I/V11e hereby authorize
(Crematory Name) j
to cremate the remains of the deceased.
FINAL DISPOSITION
The person authorized to receive the crema ed remains of the deceased from the crematory is: i
Name: al
^ C r= r 1 �(
Address: )� i'V I�1 n S -t1 t 1�<(, (� N 1 I�U ,�_Phone:
The cremated remains of deceased will be disposed of as follows: I
I �
If for any reason the person named above does not take possession of the cremated remains,
�VjQ Q�tW 1,h2OA6) f 14wv-\ is authorized to gi ve possession of
malory Name)
the remains to l�(� 1� T�h �'t �b ) b delivery'
(Funeral Home Name)
in person or by registered mail.
(Name of Deceased)
DOS-1898-f(Rev.08/15) Pag�2 of 3
1
I
Authorization for Cremation and Disposition
i
(Initial the following)
I/We understand that if the remains are not claimed within 120 days of cremation, +
&e- Ve,,J C+-e y4Jr,(lv� may dispose of th remain in
(Name of Crematory)
an irretrievable manner,such as by scattering.
CREMATION CONTAINERIURN
(Initial ONE of the following)
An urn to be used as a container for the cremated remains has been purchased from rl
and is described as follows:
I/We understand that if the urn is too small to hold the entire cremated remains,an additional rigid container may be uE ad for de very.
-OR-
An urn is/not yet purchased. I/We understand that if no um is purchased or otherwise provided
\,J ���t^e�"��"` will place the crerr ated rem ains in
(Name of Crematory)
a rigid temporary container for delivery.
This Authorization Form was provided by ► '`ark k f 1 1 vas exec ted at
(Funeral Director Name)
(Funeral Home Na
(Funeral Home Address)
i
and is signed by the funeral director as witness to its execution.
i
I
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,at est(s)
to the accuracy and completeness of the information contained in this Authorization Form and authorize(s)th foregoipg.
Signed this day of e ,201�
Typed or P ted Name (�SI nature
T^ s IU
Address
Typed or Printed Name Signature
Address
Typed or Printed Name Signature
i
Address
WITNESS: C�
M afk- k-
(Funeral Director Typed or Printed Name) uneral Director Signature)
(Re istration Number)
(Name of Deceaseaq
DOS-1898-f(Rev.08/15) Pagri 3 of 3