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New York State
Department of State
NEWYORK D'V'SiOn Of DIVISION OF CEMETERIES
STATE OF One Commerce Plaza
O TUNITY Cemeteries 99 Washington Avenue
Albany,NY 12 2 31-0 0 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 tier cremation.
Date:
1/15/2019 Number. 5-5—
Crematory Name:Pine View Crematory
Addre q-,Quaker Rd_,Queensbury,NY C L�b� 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 tD intense heat and flame. The heat and flame will Ihchwrale 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 wig 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 recognizable as skeletal tissue.
OPENING OF THE CONTAINER
The crematory may onty open the container holding the un-remated human remains in limited circumstances,such as to confirm the
identity of the deceased or to ensure that no material is enclosed which night injure employees or damage the crematory property. If
human remains are delivered in a container which is not suitable for crenu ion such as ceremordal or rental casket,the
crematory will require that the remains be moved Into a suitable container befbre 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: Edward R.Purinton Marital Status: married
Last Known Address:4117 State Rt 4,Hudson Fags,NY 12839
Place of Death:4117 State Rt.4, Hudson Falls, NY 12839
Sex: ®M ®F Age:76 DOB: 04/03/1942 Date of Death:01/15/2019 Estimated Weight: _
Description of caskeUcontainer in which remains will be delivered.
cremation casket(plywood corrugated cardboard)
PERSON IN CONTROL OF DISPOSITION
(Person(s)in control of disposition,smhal ONE of the foilbwirrg)
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.
I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
wi I ontaining directions for the disposition of his or her remains and Uwe are the person(s)Craving 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:
Edward R_Purinton
(Nxse 0f DSG-AN9
DOS-1898-f(Rev.08/15) Page 1 of ,
I
Authorization for Cremation and Disposition
(Insert from the list below)
Number: 2 Description:Surviving 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 islare 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 Pubic 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 mitten statement pursuant to Public Health
Law Section 4201(7).
(Initial ALL THREE of the following)
INVe hereby affirm that the body of the deceased does not contain a battery,battery pads,power cell,radioactive implant,
or radioactive device and that any such materials were removed prior to the execution of this Au0mrfzation Form. Failure to remove
these items prior to cremation may result in harm to the crematory and crematory personnel.
I/We affirm that instructions have been given to
Todd G.Kilmer
(Fmweral Dsedar Meme) i
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. Pure Yew Crematory
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 wM be destroyed by the cremation process and cannot be retrieved after cremation.
Pine View Crematory it
Me hereby authorize
` (Cr--uuy vane) �
to cremate the remains of the deceased. I
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name: M.B. Kilmer Funeral Home
Address:82 Broadway,Fort Edward,NY 12828 Phone: 518-747-9266
i
The cremated remains of deceased will be disposed of as follows:
Burial in Gansevoort Cemetery
If for any reason the person named above does not take possession of the cremated remains,
Pine View Crematory �
is authorized to give possession of
ra�brl
the remains to M.B_Kilmer Funeral Home by delivery
(F--W Nave Name)
i
in person or by registered mail.
Edward R_Purinton �
(Name arDeee-WM
DOS-1898-f(Rev.08/15) Page 2 of 3
i
AWmim#ion for Cremation and Disposition
tin"- the ing)
unde INVe rstand that if the remains are not claimed within 120 days of cremation,
Pine View Crematory may dispose of the remains in
(Name atcfemebw
an irretrievable mariner,such as by scattering"
CREMATION CONTAINEMURN
(Initial ONE of the fnAowing)
An um to be used as a container for the cremated remains has been purchased from
and is described as follows:
INVe understand that if the um is too small to hold the entire cremated remains,an additional rigid container may be used for delivery.
-OR-
An um is not yet purchased. UWe understand that if no um is purchased or otherwise provided
Pine View Crematory will place the cremated remains in
(Nmne ofaemakw
a rigid temporary container for delivery.
This Audwrizadon Form was provided by
Todd G.Kilmer
(Fmmat Qiator Name) was executed at
M.B. Kilmer Funeral Home
(FrmmW tome Name)
82 Broadway,Fort Edward,NY 12828
(FunoW None Addmw)
and is signed by the funeral director as witness to its execution.
INVe have received a completed copy of this Audwdzafion Form.
The person(s)identified below is/are the person(s)in control of disposition,Who by signing this Aulhorizadon Form,attest(s)
to the accuracy and completeness of the kdormadon contained in this AuOiodzaftn Form and autlwrize(s)the foregoing.
Signed this 15th day of January 2019
Ruth Purinton
Typed or Pmted Name
4117 State Rt 4,Hudson Falls,NY 12839
audmss
Typed or Printed Name
Address
Typed or Printed Name
Ad&ess N If
WITNESS:
Todd G. Kilmer
(Funeral Diector Typed or Prwkd Name) r-w—W Dseclar since)
11879
fnegis&ewn unto)
Edward R.Purinton
[Mamie WOeenaedl
DOS-1898-f(Rev.08115) Page 3 of 3