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Bessette, Frank Jr. ^ ` ° {'ioo \/ic`' (.uniciu} 8, ()umVoriom ()o`1.ko- \|(x\(\ ()ucu/shu/y. N`/ 128()/1, [� 18) 7/16'4/1-77 m� [� 18) 74J'/1,476 KcqorucdKcmn` �(��v`c________ --------------'- -_- � -'—'-- - --__--_ ----�--_--_- Dxko|,C/onix|imLku//� _ '[im, �:olcd /0��Ak�[m/cL>xn//|c|cd }`|xocdIll Kc[/iXcm|ioo., y\xrcdin Kcwn: ______ /u '[y|/uo[Coo\xjoo. ______ --_----_-_- -=-'-='=----�,^"�"���'----_-^="��=���-_-__----------------_-----_- Worr ------__--_--_---___--_--__-----------'-- ----- __--_----�------^~-� |`\Iouo| |)cxU` |�t�� 6��� �uuT� ��� �J -----_---�__--_��^c--��=.c` � �uimx/cd VVoX|o o|, \<cmxiosux| |)x|c &l'\mc 800xinx urrircJ x| Nxxvc o|' F\xncrx} [)i/zckx: m. KcOs|ord Kcsidm| Dc|irc/inK Ruox\ns__ 0uoi|u| /cxxoo for Jc\xyJ/,:mxi ill "Ic/cocm.00| oxxz /iuo �8 \v*rs ["m` Imco[xoqxcJ Jx\iv�/y � -_---------_----___------- _' ' _� -' 'Rctovt Numbcv Nvo`hc/ It, w\`\J` Kuo^ios °n, No(c ll`c 6o`` i^`� s|uU \v ',c:`in,J io (tic. |`,:.xm,o, Fi|c o[ /|'c Cmouo,[ ' i New York State NEW PORK D' � Department of State STATE OF V'�' n O DMSION OF CEMETERIES OPPORTUNITY. One Commerce Plaza Cemeteries 99 Washington Avenue Albany,NY 12231-0001 Telephone:(518)47"226 Authorization for Cremation arid Disposition www.dos.ny.gov This Authorization Form must be completed and signed prior to delivery of remains for cremation. Date: ' 1 1 S"1 Number: 51 Crematory Name: Pine View Crematorium Address: Quaker Road ,Queensbi iry New York 12887 Phone: 518 745 4477 CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS. Cremation is carried out by placing the remains of I ie deceased and the container holding the remains into a cremation chamber where they are subjected to intense heat and flame. The isat 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 reasor able 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 desiS nated container or um. Cremated remains generally are pulverized until no single fragment is recognizable as skeletal tissi Is. 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 materi I is enclosed which might injure employees or damage the crematory property. If human remains are delivered Ina container whi h is not suitable for cremation such as ceremonial or rental casket,the crematory will require that he remains be mo Into a suitable container before it accepts the remains. The opening of a container or the transfer or removal of remains will a conducted before a witness and will be done in privacy,with dignity and respect _IDENTIFICATION OF DECEASED I i Name of Deceased: j(/�]/Z k �-- �T�12 Marital Status: Last Known Addre •_Z&29 Place of Death: Sex:/WM © F Age: DOB: Date of Death: // ZD/ Estimated Weight: 3 Description of casketicontainer in which remains wil I be delivered. ,i-- i 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. -OR- I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 0 � containing directions for the disposition of his or her remains and I/we are the person(s)havin r a Section 4201 and have the right to authorize creme on of the remains of the deceased. y/Our relationship to he ldeceased Is as follows: (Nam*of Dec--Q DOS-1898-f(Rev.08/15) Page 1 of 3 l Au i Authorization for Cremation a d Disposition (insert from the list below) Number: .3 Description: SO v'i. 1. A person designated in writing pursuant to�ublic Health Law Section 4201(3); 2. The surviving spouse; 2a. The surviving domestic partner, 3. Any surviving child eighteen years of age older, 4. A surviving parent; 5. A surviving sibling eighteen years of age o older; 8. A lawfully appointed guardian; 7. Any person(s)eighteen years of age or old r entitled to share in the estate and who istare 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 dministrator appointed pursuant to the Surrogate's Court Procedure Act; 10a. Any other person who is acting on behalf oi the deceased and who has executed a written statement pursuant to Public Health Law Section 4201(7). (Initial ALL THREE of the following) I/We hereby affirm that the body of th�deceased does not contain a battery,battery pack,power cell, radioactive implant, or radioactive device and that any such materials ere removed prior to the execution of this Authorization Form. Failure to remove these items prior to cremation may result In h to the crematory and crematory personnel. �a I/We affirm that instructions have beer given to Jay T.Jillson � (Funeral Director Nerve) regarding the removal of any personal property or ether thing of value which any person signing below or any family member of the deceased wishes to preserve. Pine Yiew Crematorium (crernerory Name) is not responsible for the removal of personal item 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. I/We hereby authorize ine View Crematorium (Cremarory Na—) to cremate the remains of the deceased. FINAL DISPOSITION The person authorized to receive the cremated re ains of the deceased from the crematory is: Name: Jay T.Jillson Address: 46 Williams Street Whitehall New York 12887 518 4991040 Phone.- The cremated remains of deceased will be dispo of as follows: I '1 Uc 2, L - itL�t rt� C 1 ' � r If for any reason the person named above does no take possession of the cremated remains, Pine View Crematorium is authorized to give (�mn ) g' possession of the remains to Jillson Fune I Home Inc. by delivery (Funeral Nome Name) in person or by registered mail. ' (Name o/Deoesaed) j DOS-1898-f(Rev.08/15) Page 2 of 3 i Adthorization for Cremation and Disposition R (Iniiya(ll the following) _I/We understand that if the remains are not claimed within 120 days of cremation, Pine View Crematorium (N. OfCMnebw may dispose of the remains in an irretrievable manner,such as by scattering. CREMATION CONTAINE /IiRN (Initial ONE of the following) An um to be used as a container forth cremated remains has been purchased from 7 f tl3 otJ and is described as follows: $ C u FlAq:TC (0 Ij TA 3 0� I/We understand that if the um is too small to hold a entire cremated remains,an additional rigid container may be used for delivery. -OR- An um is not yet purchased. I/We and rstand that if no um is purchased or otherwise provided Pine View Cremato'um (Name Ofcre will place the cremated remains in a rigid temporary container for delivery. � This Authorization Form was provided by Jay T.Jillson was executed at (Funeral Dlredor Name) Jillson Funeral Home Inc. (FwWal46 Williams Street Whitehall New�york 12887 rams ) (Funeral Home Address) and is signed by the funeral director as witness to it�execution. �Zatfon i I/We have received a completed copy of this Auth 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 Inform tIon contained In this Authorization Form and authorize(s)the foregoing. Signed this day of Y0 Typed or Printed Name "" 1�EL /ag"�j! T PO Wt-7T Lc- /V 'g7 Address 41 TWedorP~AWm srt>nawra Address Typed or Pdrftd Name Slynature Addrese WITNESS: Jay T.Jillson (Funeral Director Typed or Pm1ed Namo) ) 11747 (Name o/Deeeased) DOS-1898-f(Rev.08115) Page 3 of 3