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New York State
Department of State
NEW YORK pivision of DIVISION OF CEMETERIES
One Commerce Plaza
STATE OF 99 Washington Avenue
OPPORTUNITY. Cemeteries 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:
01/30/2019 Number: 2019#12 / 9'C
Crematory Name: Pine View Crematory
Phone: (518) 745-4477
Address: 21 Quaker Rd., Queensbury, NY 12804
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 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
d into a designated container or urn. Cremated remains generally are pulverized until no
pulverized into small pieces and place
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
Arthur Harrison Morehouse Marital status: Divorced
Name of Deceased: i
Last Known Address: 8 Grand Ave., Warrensburg, NY 12885
Place of Death: , 8 Grand Ave., Warrensburg, NY 12885
Sex: ®M [IF Age: 53 DOB: 09/12/1965 Date of Death: 01/30/2019 Estimated Weight: 100
Description of casket/container in which remains will be delivered.
Florence Casket deluxe cremation container
I
PERSON IN CONTROL OF DISPOSITION
(Person(s)in control of disposition, initial ONE of the following)
I amANe are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
Health Law Section 4201.
-OR-
IMe have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or al
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:
Arthur Harrison Morehouse
(Name of Deceased)
DOS-1898-f(Rev. 08115)
Paapl�t�
Authorization for Cremation and Disposition
(Initial the following)
[".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 CONTAINER/URN
(Initial ONE of the following)
Alexander-Baker Funeral
An urn to be used as a container for the cremated remains has been purchased from (. ..,..
and is described as follows:
INVe understand that if the urn is too small to hold the entire cremated remains, an additional rigid container may be used for delivery.
-OR-
-- An urn is not yet purchased. 1/We understand that if no urn is purchased or otherwise provided
Pine View Crematory will place the cremated remains in
(Name of Crematory)
a rigid temporary container for delivery.
This Authorization Form was provided by David H. Alexander was executed at
(Funeral Director Name)
Alexander-Baker Funeral Home
(Funeral Home Name)
3809 Main Street, Warrensburg, NY 12885
(Funeral Home Address)
and is signed by the funeral director as witness to its execution.
IMe 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 contained in this Authorization Form and authorize(s)the foregoing.
Signed this 30th day of January , 20 19
Tammy L. Morehouse �f A
Typed or Printed Name nature
26 Grand Avenue, Warrensburg, NY 12885-
Address
Typed or Printed Name Signature
Address
Typed or Printed Name Signature
Address
WITNESS:
David H. Alexander
(Funeral Director Typed or Printed Name) (F eral 'ector Signs ure)
10034
( egistration Number)
Arthur Harrison Morehouse
(Name of Deceased)
Page 3 of 3
DOS-1898-f(Rev. 08/15)