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Funfgeld, Mary I'll* Vick ' (.`nllc!u y & ()z/oxxxivm (>oxko- \\oxd [}oru/s|w/y. NY 1280/1, [� 18) 74"),'4477 m 18) 7/J.]'/1./1,7(� Fmmx| Homc �� /ko�--_______ |<o|o,/|,J �^ [ �`/, N . �` � '—/��_'---'----'-- [mxe �umx| ./u��/��|�mx� L)m/|,|c/cd_.�/'� ]0 ` —_— y1xnx\ io Hold: }`|^ocJ ix . \ |xru| iu R(Acil xI: _ l`y|mo[comxioa __c� ��r�/��l� j.;y., co.�u�-�� ' ----'--- '- ----------------------------......... ----------------------- Am |`|^,cv| I'mim,/o| VVcip,lo o[ Kmui Ism Id [onuino__/�O_/�'� ' ' |)^|, & llmc Kooxms u/ircJ x| C/uo`mxY_ �°jLo7�/� Nxmco|, Ill un| Di/rrkx. orKc b|nn| |\,sidnxDc|iro1xgRoo-(Iins_-�' _ _ Dcmi\u\ /xxu/n |,orJcbyJ /��mxin` wz/cnnn.oni vm/� J`.m '|8 |v"o� |,vm I�m, o| ^o qon| J r\� I"o/y -----_--_-__-----__-----_ - — — - ---' -----------'_-- �- Kuoo Nmo\v:, �it, w\x(\/� \( | ��p«r cvux`` °n.� nv.ux` -�!w fir --l��.�--'_-----_-- No|cll`c (x,mx(io`` i /`� /|`xU (., .u:.Ion| "` /|.c |`nm^on`/ [Uc o( /\* (�/�`"m,>� � $g'4 NYS Deparlyient of State Derision of Cen►ateries One COMMe Plaza,99�ban�yton 2nue AuthQrizat►on for Cremation and Disposition (518)47�226 31 www.dos"nTus feted and signed prior to delivery of remains for cremation. This Authorization Form must be comp 9 �� Number: Date: 1 Crematory Name: Pine View Crematory Phone: 18) Address: Quaker Road, Queensbu , N 12804 (5 745 ew York -4477 CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS. The heat and flame will incinerate and Cremation ise.carried out by placing remains of the deceased 'alla container holding the remains into a cremation chamber where they are subjected 1,intense hea l t remove all of the remains and other.material from �n except bone and metal,which are all that will be left after cremation- consume everyth• g will take reasonable efforts to The crematory wll separate Following cremation,the crematorybe the cremation chamber, but some minimal dust and incidental and lreignema behind. will be disposed of as incidental and foreign material from the remains fragment is b law.The cremated remains will be mechanically aruely pulverized until no single frpag ced in o a required y generally pulverized designated container or um. Cremated remains9 recognizable as skeletal tissue. such OpENurdc' OF CON_'[AINER ato may only open the container holding the un-cremateda human enclosed which might injure employees or The crematory Y as to confirm the identity of the deceased or to ensure that no mate ins o moved into a suitable such as a ceremonial or rental casket,the crematory o property. If human ins are delivered in a container �s not suitable for cremation damage crematory p Pe remain will require that the ma fore it accepts the remains.The opening of a container or the transfer or removal of remains will e container be ni and respect. conducted before a witness and will be done in privacy,with di dignity n�NTIFIGATION OF DECEASED 9 b Marital Status:—I U , Name of Deceased. 1 Last Known Address: `ma's Place of Death: Sex: ❑M Age. DOB: K �27, Date of Death:]L:��Estima�dWeight: Description of casket/container in which remains will be delivered: i`11�wi t L C Vvv;, Zc �S6 nrf ===iUM =ONof (Person(s 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. -ORXI I/We have no knowledge that the deceased executed ai written her rema remains andpursuant cont<nued next page) Health Law section 4201 or a will containing directions for the disposition of h r. G bLd I am/we are the person(s) having priority under Public Health Law section 4201 and have the right to authorise (Insert from the list below) + cremation of the remains of the deceased. My/Our relationship to the deceased is as follows: R. , Number:_ Description: So ,. 1.A person designated in writing pursuant to Public Health Law section 4201(3); 2. The surviving spouse; 2a. The survivina do tic partner, 3.Any surviving child eight ears 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 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). (Initi al ALL THREE of the following) / I/We hereby affirm that the body of the deceased does not contain a battery, battery pack, power cell, radioactive 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. 1 INVe hereby affirm that instructions have been given to(funefaidirecwname) Starr Baker LFD#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. (cmmatoiyname) Pine View Crematory is not responsible for removal of personal items from the container or from the remains of the deceased. Personal items eft in the container or with the remains will be destroyed by the cremation process and cannot be retrieved after cremation. I/We hereby authorize(cmmatmy name) Pine View Crematory to cremate the emains of the deceased. INAL DISPOSITION he person authorized to receive the cremated remains of the deceased from the crematory is: lame: Maynard D. Baker Funeral Home ddress: 11 Lafayette Street, Queensbury, New York 12804 Phone: (518) 761-9303 ie cremated remains of deceased will be disposed of as follows: RETURN TO FAMILY or any reason the person named above does not take possession of the cremated remains, matmy name) Pine View Crematory is authorized to give possession of the remains to Ma na�dD.Baker Funeral Home by delivery in person or by registered mail. I U�tj page 2 of 3 ruanxq of Deceased s � (i .�tho following) I/We understand that if the remains are not claimed within 120 days of cremation, (crematory name) Pine View Crematory may dispose of the remains in an irretrievable manner, such as by scattering. CREMATION CONTAINER/URN (Initial ONE of the following) An urn to be used as a container for the cremated remains has been purchased from Maynard D. Baker Funeral Home 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 used for delivery. An urn has not yet been purchased. I/We understand that if no urn is purchased or otherwise provided (crematory name) Pine View Crematory will place the cremated remains in a rigid temporary container for delivery. This Authorization Form was provided by (funeral director name) Starr Baker LFD#10159 was executed at (funeral home name) Maynard D. Baker Funeral Home (funeral home address) 11 Lafayette Street, Queensbury, New York 12804 and is signed by the funeral director as witness to its execution. 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, attests) to the accuracy and completeness of the information contained in this Authorization Form and authorize(s) the foregoing. Signed this �- day of T u ) 9 l t Typed or Printed Name Signature Address Typed or Printed Name Signature Address Typed or Printed Name Signature Address WITNESS: Starr Baker LFD#10159 Funeral Director Typed or Printed Name Funeral rrec or Sign re Funeral Home Reg. #01130 Registration Number fyt �UA) r-c ti(j DOS-1898-f-I (Rev.01/10) Name of Deceased Page 3 of 3