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NYS Department of State
Authorization for Cremation and Disposition Division of Cemeteries
One Commerce Plaza,99 Washington 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.
Date: ;~';--S — 1 A Number: 4�
Crematory Name: Pine View Crematory
Address: 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 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 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.
OPENING OF 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 crematory property. If human remains are delivered in a container which Is not suitable for cremation
such as a 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: Rr( I( & Marital Status: l�
Last Known Address: UPp ne;5 r-L lV i/ /25�o�-1 _
Place of Death: A F-
Sex: XM ❑F Age: -1 (p DOB: c� / � Date of Death: Estimated Weight: /P(-)
Description of casket/container in which remains will be delivered:
Corrugated Cardboard Box with Plywood Starmark Model #38808
PERSON IN CONTROL OF DISPOSITION
(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
pursuant to Public Health Law section 4201.
-OR-
INVe have no knowledge that the deceased executed a written instrument pursuant to Public Health Law
se ion 4201 or a will containing directions for the disposition of his or her remains and (Continued nextpage)
DOS-18984-1 (Rev. 12/11) Name of Deceased Page 1 of
I am/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:
(Insert from the list below)
Number: Description:
A person designated in writing pursuant to Public Health Law section 4201 (3);
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 is/are closest in
relationship to the deceased;
S.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).
(Initial ALL THREE of the following)
Vk 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.
IM/e hereby affirm that instructions have been given to (funeral dlrectorname) Starr Baker #10159 regarding
the
oval of any personal property or other thing of value which any person signing below or any family member of the
deceased wishes to preserve. (crematory name) Pine View Crematory is not responsible for
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.
I/We hereby authorize(crematory name) Pine View Crematory to cremate the
re sins of the deceased.
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name: Baker Funeral Home Personnel
Address: 11 Lafayette Street Queensbury, New York 12804 Phone: (518) 761-9303
The cremated remains of deceased will be disposed of as follows:
Return to family to be decided
If for any reason the person named above does not take possession of the cremated remains,
(crematory name) Pine View Crematory is authorized to give possession of the remains to
(funeral home name) Baker Funeral Home by delivery in person or by registered mail.
ruse �� IL j
DOS-1898-f-J(Rev.01/10) Name of Deceased Page 2 of 3
&!�/the following)
INVe 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
Barer 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.
-OR-
An um 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#10159
was executed at(funeral home name) 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.
Me 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 day of r 0CL41,1- , 20 ( �j .
E,k &16-11
Typed or Prin a Name ' nature
d ry 2�c�
Address
Typed or Printed Name Signature
Address
Typed or Printed Name Signature
Address
WITNESS:
iAA1 M '0Y'0J0_1
Funeral Director Typed or Printed N e Funeral Director Sign u
Funeral Home Reg. #01130
Registration Number
�ruc� )�
DOS-18984-1 (Rev.01/10) Name of Deceased Page 3 of 3