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Nolc: The CI-cimthon 1 .ogdl;lII I)(' Ickmu'd in Ill(! PCIM:klw1l( I.,i1c ()I 111c Crclll;t(ory
New York State `
N EW YORK Department of State
Division of DIVISION OF CEMETERIES
STATE OF One Commerce Plaza
OPPORTUNITY_ Cemeteries 99 Washington Avenue
Albany,NY 12231-0001
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 for cremation.
Date: <-y` I I Number. C* O
Crematory Name:Pine View Crematory
Address:_.)-I CLvq I«S K d Q V e.(.,,S b v e y A1I-1 Phone:
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 heat and 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 all of the remains and other material from the cremation
chamber,but some minimal dust and residue PA 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 um. Cremated remains generally are pulverized until no
single fragment is recognizable as skeletal tissue.
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 material is enclosed which might injure employees or damage the crematory property. If
human remains are delivered in a container which is not suitable for cremation such as ceremonial or rental casket,the
crematory will require that the remains be moved into a suitable container before 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: ("/ S Marital Status:
I ;�T
Last Known Address: �.3�/ 5 rl� hl rA) i V e-rL',q /11,X' '
Place
,,of�//Death: �3Y S/� /'1- a�d�l M,ry enm /U;x' Z
L�9-
Sex: M ❑F Age: DOB: Q a� 3 Date of Death: G/ t7..�i! Estimated Weight Z
Description of casket/container in which remains will be delivered. � 1
vCin►'eknA ler�U%l " U 'k'� l�d7l��v 6C-Lf—jc
PERSON IN CONTROL OF DISPOSITION
(Per�sonn(s))iin control of disposition,initial ONE of the following)
--J�1— 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 or a
will containing directions for the disposition of his or her remains and I/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: _
Z 1�o y sX �rlm in�a9 S
(Nano w99M
DOS-1898-f(Rev.08/15) Page 1 of 3
Authorization for Cremation and Disposition y
(Insert from the list below) ))
Number. Description:
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,
S. 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 dose 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 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 Section 4201(7).
(initial 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.
v
Jell I/Weaffirm that instructions have been given to ;T6�0 I
� /
(wnwW Dir8CWName)
regarding the removal of any personal property or other thing of value which any person signing below or any Tamil member of the
deceased wishes to preserve. Pine View Crematory
(Crematory Name)
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 will be destroyed by the cremation process and cannot be retrieved after cremation.
Lf--I/We hereby authorize Pine View Crematory
(Crematory Name)
to cremate the remains of the deceased.
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name:Any Staff from the Edward L. Kelly Funeral Home
Address: 1019 US Rt.9 PO Box 548,Schroon Lake,NY 12870 Phone: 518-532-7177
The cremated remains of deceased will be disposed of as follows:
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
(Crematory Name)
the remains to Edward L Kelly Funeral Home by delivery
(Funeral Home Name)
in person or by registered mail.
� c®y' "-T e,UmmiNV
(Name of Da—seO
DOS-1898-f(Rev.08115) Page 2 of 3
Authorization for Cremation and Disposition
(Ini" I the following)
I/We understand that if the remains are not claimed within 120 days of cremation,
Pine View Crematory may dispose of the remains in
(Name of Crematory)
an irretrievable manner,such as by scattering.
CREMATION CONTAINERIURN
(initial ONE of the following)
An urn to be used asa container for!the cremated rem-gains has been purchased from Edward L Kelly Funeral Home
and is described as follows: A 1�A f-J U� c `J�S/) e__
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-
u is n t yet haa� sed. IIWe u -,- I r i�f no um is purch o therwise prtwicf
will place the cremated remains in
(Name of Cm )
a rigid temporary container for delivery"
This Authorization Form was provided by �� was executed at
(Funeral Director Name)
Edward L Kelly Funeral Home
(Funeral Home Name)
1019 US Rt.9,PO Box 548 Schroon Lake, NY 12870
(Funeral Home Address)
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,attest(s)
to the accuracy and completeness of the information c ntained in this Authorization Form and authorize(s)the foregoing.
Signed this .r/ day of A ils4�^ .20
S�1 CAIo A�
Typed or We dp�ame� signature
rf` � (a r
MOMSS
Typed orPdnted Name signature
Address
Typed or Printed Name Signature
Address
(Funeral Direct, Typed q km Name) (F signature)
(Registration Number) /(/
(Name of Deceased)
DOS-1898-f(Rev.08/15) Page 3 of 3
Pine View Cemetery and Cretmlorium
21 Quaker Road
Queensbury, NY 12804
Authorization t0 Separate Cremated Remains
Funeral Home -------------- �LC�
Director---------------------- -alk-
-------------------------
Date ----------------hag, No.---------b ------
- -- ----
---------------- -
I/wc autllorirc the separation of tlic crculatcd rcnlains 0I
---------------------- >^R04----LUKMje_- 5----------------------------
I/we I111-thcr ag-CC to hold Ilar1111Css, 111deninity and (Ietelld t11C herein ►Bulled crematorium as well
as 11161- 1'Cpreselltat►ves, Ir011l and against all claims, liabilitics or damages whatsoevu which may
l-esult f1,0111 this au 101 ZatiO11.
Sigilaturc _ ------------- ----- -- ------------ ------------------
Crematory Operatorr -------------------- ------ ------- ----------------
1
March 2015