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NYS Department of State
Division of Cemeteries
One Commerce plaza,99 washi Albany nY 12231
,Authorization for Cremation and Disposition (518)4 12226
31
Hww.dos.ny.us
rior to delivery of remains for cremation.
This Author
ization Form must be completed and signed p
Number: S6
Date: 11 t
Crematory Name: Pine View Cremato
Address: Quaker Road, Queensbury, New York 12804
Phone: f518)745-4477
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS. flame.The heat and flame will incinerate and
Cremation is ca rried out by placing the remains of the deceased and the container holding the remains into a
cremation chamber whereexcept bone and metal,which are all that will be left of thefter ati remains and other material from
consume everything p will take reasonable efforts to remove ind. The crematory will separate
Following cremation, the crematory
the cremation chamber, but some minimal du andnd rthe incidentaesidue will l and foeeignhmate al will be disposed of as
incidental and foreign material from the remains
pulverized until no single fragment is recognizable
b law. The cremated remains will be mechanically pulverized into small pieces
requiredand placed too a
Y are p
designated container or urn. Cremated remains generally
as skeletal tissue.
OPENING OF CONTAINER
only open the container holding the un-cremated human remains in
injure employees or,
The crematory may Y o material is
as to confirm the identity of the deceased or to ensure that n
to property. If human remains are delivered in a contains'mains be movedbnto arsuitableon
damage a ceremonial
crematory p p will require that th
such as a ceemonial or rental casket,the crematory
container
before it accepts the remains. The opening of a container
or the spectransfer or removal of remains will e
conducted before a witness and will be done in privacy, with dignity
IDENTIFICATION OF DECEASED Marital Status: YY-Yk
Name of Deceased:
Last Known Address:
Place of Death:
Sex. M ❑F Age: _DOB: Q
Date of Death: l � rj Estimated Weight:
Description of cas
ket/container in which remains will be delivered:
Corruga
ted Cardboard Box with Plywood Starmark Model#38808
PERSON IN CONTROL OF DISPOSItgI TION
E of the following)
(Person(s)in control of disposition, irnt
I am/We are the designated agent of th
e deceased designated in a will or written instrument executed j
pursuant to Public Health Law section 4201.
-OR-
IIVNe have no knowledge that the deceased executed a written instrument pursuant to Public Health Law
se ion 4201 or a will containing directions for the disposition of his or her remains and (C0/7tin1A9d nsxtngaA)
i
I+am/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:
(Insert from the list below)
Number:__2_Description: �
A person designated in writing pursuant to Public Health Law section 4201 (3);
Phe 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§4201(7);
10. A chief fiscal officer of a county or a public administrator appointed pursuant to the Surrogate's Court I
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§4201(7).
LL TTHREE of the following)
(,J lMe 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. Failure to remove these items prior to cremation may result in harm to the crematory and
crematory personnel.
M�kJ IMIe hereby affirm that instructions have been given to (funeral director name) Starr Baker #10159 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. (crematory name) Pine View Crematory is not responsible for
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.
U V W I/We hereby authorize(crematory name) Pine View Crematory 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:
i
Name: Baker Funeral Home Personnel
Address: 11 Lafayette Street Queensburv. New York 12804 Phone: (518) 761-9303
The crem
ated remains of deceased will be disposed of as follows:
Return to family to be decided
above does not take possession of the cremated remains,
If for any reason the person named a p �
(crematory name) Pine View Crematory is authorized to give possession of the remains to
(funeral home name) Baker Funeral Home by delivery in person or by registered mail.
I
DOS-1898-f-J(Rev.01/10) i
(Initial;rynme,)_Pine
following)
Me understand that if the remains are not claimed within 120 days of cremation,
(cremat View Crematory may dispose of the remains in 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
Baker Funeral Home 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
fo;8name)
.
- An urn has not yet been purchased. 1/We understand that if no urn is purchased or otherwise provided
(c Pine View Crematory will place the cremated remains in a rigid temporary
Crematory-
container for delivery. I
This Authorization Form was provided by(funeral director name) Starr Baker#10159
W8S executed at(funeral home name)
Baker Funeral Home j
(funeral home address) 11 Lafayette Street Queensbury New York 12804 and is signed by the funeral director
as witness to its execution.
I
Me 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, attests)to the accuracy and completeness of the information contained in this Authorization Form and
authorize(s)the foregoing.
Signed this 9 day of U 0. 4S,,gnatu
2U �'
Typed or Printed Name •-z.
Address
Typed or Printed Name Signature
Address
Typed or Printed Name Signature
Address
I
WITNESS:
Funeral Director Typed or Print m F uneral Director Signature a e /
Funeral Home Reg.#01130
Registration Number
DOS-1898-r--1 (Rev_ntilnm ���l�iW^/A//