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New York State
Division of Department
FCEM�s��
NEW PORK Division� DIVISION OF CEMETERIES
STATE OF One Commerce Plaza
OPPORTUNITY. Cemeteries 99 Washington Avenue
Albany,NY 12231-0001
Telephone:(518)47"226
www.dos.ny.gov
Authorization for Cremations and Disposition
This Auiborizadon Form must be completed and signed prior to delivery of remains for cremation.
2/4/2019 /0 q
Date: Number.
Crematory Name:Pine View Crematory
Address:Quaker Rd.,Queensbury,NY M!l 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 heat and flame. The heat and Game wili incinerate and consume everyff*V except bone and metal,
which are all that wM be left alter cremation.
Following cremation,the crematory wig take reasonable efforts to remove all of the remains and other material from the cremation
chamber, but some minimal dust and residue wr716kely be left behind. The crematory will separate incidental and foreign material from
the remains and the incidental and foreign material wig be disposed of as required by law. The cremated remains Willi be mechanically
pulverized into small pieces and placed into a designated container or um. Cremated remains generally are pulverized until no
single fragment is rule as skeletal tissue.
OPENING OF THE CONTAINER
The crematory may only open the container holding the un-remated human remains in limited circumidarrces,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 nunred into a suitable container before it arxrepts the remiaars. 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�OjF DECEASED
S
Name of Deceased Michael O Marital Status: married
Last Known Address: ��if IL i Ili, f S �l"�
Place of Death: Glens Falls Hospital,Glens Falls, NY
Sex: ®M El F Age:73 DOB: 06/12/1945 1 Date of Death:2/3t19 Estimated Weight: _
Description of casketilcontairor it which remains will be ivered.
cremation casket(plywood corrugated cardboard) GO(t�JQE
PERSON IN CONTROL OF DISPOSITION
(Person(s)in control of disposition,initial ONE of the meowing)
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-
INVe 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 Uwe 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. MyfOur relationship to the deceased is as
follows:
�00-t j Michael O'Sick
r�d
DOS-1898-f(Rev.08115) Page 1 of 3
Authorization for Cremation and Disposition
(lnseft from the tilt below)
2
A
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,
6. A lawfully appointed guardian;
7. Any person(s)eighteen years of age or older entitled to share in the estate and who islare 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 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 foAowing)
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 AuMoriza0an Form. Failure to remove
these Items prior to cremation may result in harm to the crematory and crematory personnel.
I/We affirm that instructions have been given to Todd G.Kilmer
(Fre�evae Diecb Name)
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.
Pine Yew Crematory
Xhw-tvy Ha—)
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.
y4ee—1 Il11Ve hereby authorize Pine View Crematory
(paaelo►y Hems)
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: M.B.Kilmer Funeral Home
Address:82 Broadway,Fort Edward,NY 12828 Phone: 518-747-9266
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 Yew Crematory is authorized to give possession of
[may )
M.B.Kilmer Funeral Home delivery
the remains to �
(Fa�era/Nine )
in person or by registered mail.
�bo%t) iulidhaei O'Sick
(Mrne dOeces�edj
DOS-1898-f(Rev.08/15) Page 2 of 3
Audwization for Cremation and Disposition
(initial the following)
70 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 orc fenny)
an irretrievable manner,such as by scattering.
CREMATION CONTAINERNRN
(Initial ONE of the follow ft)
An um 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.
YOR-
� An um is not yet purchased. UWe understand that if no um is purchased or otherwise provided
Pine View Crematory will place the cremated remains in
(Name d C +Y)
a rigid temporary container for delivery_
This Authorizafta Form was provided by Todd G.Kdmer
was executed at
sera/ahwi-Name,
M.B. Kilmer Funeral Nome
(FrmeralH—Name)
82 Broadway, Fort Edward,NY 12828
(Fa-W H—Ad*-V
and is signed by the funeral director as witness to its execution.
INVe have received a completed copy of this AubWzaMm Form.
The person(s)identified below Ware the person(s)in control of disposition,who by sign**this Audiodtatlon Form,attest(s)
to the accuracy and compleftness of the information contained in this Au0mlzaron Form and auftmize(s)the foregoing.
Signed this 4th day of Feb. '20 2019 5
.Susan O'Sick - d'w
T y ed nNa ;1 q
Address
Typed or Printed Name
Address
Typed orJ3mted Name
Address
WITNESS:
Todd G. Kilmer
(Funeral Drectcr Typed or Pholed Name) (Funeral Died-sig-h-)
11879
(Regb"Non Number)
\tj Michael US"
tX—arna«...*
DOS-1898-f(Rev.08115) Page 3 of 3