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NYS Department of State
I uth�orization for Cremation and Disposition Division of Cemeteries
One Commerce Plaza,99 WasNngton Avenue
Albany,NY 12231
(518)474-6226
www.dos.ny.us
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
)ate: _ J III Number.
;rematory Name: Pine View Crematory
lddress: Quaker Road, Queensbury, New York 12804 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 to intense heatand flame.The heat 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 reasonable efforts to remove an 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 urn. Cremated remains generally are pulverized until no single fragment is recognizable
as skeletal tissue.
IPENING OF CONTAINER
'he crematory may only open the container holding the un-cremated human remains in limited circumstances, such
s to confirm the identity of the deceased or to ensure that no material is enclosed which might injure employees or
amage crematory property. If human remains are delivered in a container which is not suitable for cremation
uch as a ceremonial or rental casket,the crematory will require that the remains be moved into a suitable
ontainer before it accepts the remains.The opening of a container or the transfer or removal of remains will be
onducted before a witness and will be done in privacy, with dignity and respect.
)ENTIFICATION OF DECEASED
Vame of Deceased: Marital Status: �,Y «
_ast Known Address: lef-gA M.FA1DOIo< (,t� ��, /V o000
glace of Death: EMA x:�
Sex: ❑M of Age:, DOB: Date of Death: Estimated Weight: �� I
I
3escription of casket/container in which remains will be delivered: j
Corrugated Cardboard Box with Plywood Starmark Model #38808
3ERSON IN CONTROL OF DISPOSITION i J
I
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
>ursuant to Public Health Law section 4201.
OR-
UWe have no knowledge that the deceased executed a written instrument pursuant to Public Health Law
>e o 4201 or a will containing directions for the disposition of his or her remains and (Continued ne'xt/page)
)OS-1898-f-1 (Rev. 12/11) Name of Deceased Page 1 of 3
I
am/we are the person(s)having priority under Public Health Law section 4201 and have the right to authorize
vemation of the remains of the deceased. My/Our relationship to the deceased is as follows:
Insert from the list below) p
Number: 7 Description: R PD WF-
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;
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
Procedure Act;
1 Oa.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).
nitial ALL THREE of the following)
,d*INVe hereby affirm that the body of the deceased does not contain a battery, battery pack, power cell,
ativlmplant, or radioactive device and that any such materials were removed prior to the execution of this
uthorization Form. Failure to remove these items prior to cremation may result in harm to the crematory and
rernatorV personnel.
e hereby affirm that instructions have been given to (funerwdiredcrname) Starr Baker #10159 regarding
ie val of any personal property or other thing of value which any person signing below or any family member of the
eceased wishes to preserve. (crematayname) Pine View Crematory is not responsible for
;moval of personal items from the container or from the remains of the deceased. Personal items left in the container or
Flthjqq remains will be destroyed by the cremation process and cannot be retrieved after cremation.
i s
IIWe hereby authorize(crematory name) Pine View Crematory to cremate the
of the deceased.
INAL DISPOSITION
he person authorized to receive the cremated remains of the deceased from the crematory is:
ame: Baker Funeral Home Personnel
address: 11 Lafayette Street, Queensburv, New York 12804 Phone: (518) 761-9303
'he cremated remains of deceased will be disposed of as follows:
Return to family to be decided
for any reason the person named above does not take possession of the cremated remains,
rematorynwv) Pine View Crematory is authorized to give possession of the remains to
inera►home name) Baker Funeral Home by delivery in person or by registered mail.
OS-1898-f-J(Rev.01/10) Name of Deceased Page 2 of 3
I
Xor
th llowing)
/We understand that if the remains are not claimed within 120 days of cremation,
Pine View Crematory may dispose of the remains in an irretrievable manner,
;uch as by scattering.
:REMATION CONTAINER/URN
Initial ONE of the following)
An um to be used as a container for the cremated remains has been purchased from
Baker Funeral Home and is described as follows:
We understand that if the urn is too small to hold the entire cremated remains, an additional rigid container may be used
Dr delivery.
qOr
n um has not yet been purchased. INNe understand that if no um is purchased or otherwise provided
yname) Pine View Crematory_ will place the cremated remains in a rigid temporary
ontainer for delivery.
'his Authorization Form was provided by(luneraldirectmname) Starr Baker#10159
ras executed at(funera►home name) Baker Funeral Home
unera/h«ne rk 12804 and is signed by the funeral director
is witness to its execution.
We have received a completed copy of this Authorization Form.
'he person(s) identified below is/are the person(s) in control of disposition,who by signing this Authorization
'orm,attest(s)to the accuracy and completeness of the information contained in this Authorization Form and
uthorize(s)the foregoing.
�t.1 Q
ligned this �' day of z.1201
Typed or Printed Name
addreyss
Typed or Printed Name Signature
Address
Typed or Printed Name Signature
Address
VITNESS:
Funeral Director Typed or Printed Name Funeral Lw nature
Funeral Home Reg.#01130
Registration Number
)OS-18Wf-I (Rev.01/10) Name of Deceased Page 3 of 3