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NYS Department of State
Authorization for Cremation and Disposition DMWM of cemeteries
one Commerce Plaza,99 VAW*gton Avenue
Albany,NY 12231
(518)474-6226
wwwAos.state.ny.us
This Authorizedon Form must be completed and signed prior to delhrery of remains for cremation.
Date: o? / Number. 7,3
Crematory Name: iU' �)
T
Address: ��L c C ,+.£� ti A� 1�Rhone����=7�/S- WV
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 pulverized into small pieces and placed into a
designated container or um. Cremated remains generally are pulverized until no single fragment is
�ecognizabie as skeletal tissue.
�ENIN 3 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.
i
IDENTIFICATION OF DECEASED �/
Name of Deceased: /.�'AV2-= l ovks Marital Status: r-
Last Known Address: /%[Ir �.}/�/ 4%rc) �-E A'y'
Place of Death: ram-E�AS S -c��S -C; 7✓1-�-
Sex: SM OF Age: DOB: r` �V/H J Date of Death�,2 ? C i` Estimated Weight 74
Description of casket(container in which remains will be delivered:
PERSON IN CONTROL OF DISPOSITION
(Person(s)in control of disposition,initial ONE of the following)
1 am/We are the designated agent of the deceased designated in a will or written instrument executed
I
pursuant to Public Health Law section 4201.
-OR-
iN1/e have no knowledge that the deceased executed a written instrument pursuant to Public Health Law
l0 4201 or a will containing directions for the disposition of his or her remains and (Continued next page)
2 L--,A�—�=---_
DOSA 898 N (Rev.01110) Name of Deceased Page 1 of 3
I
I arrdxe 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: 9 Description: t!;�469 e-
1.A person designated in writing pursuant to Public Health J..aw 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 entrbed 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 Surrogates 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).
( '' ALL THREE of the following)
fillxjMe hereby affirm that the body of the deceased does not contain a battery, battery pack, power cell, I
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 I
c matory personnel.
i
I/We hereby affirm that instructions have been given to puneral dNmw name) �J ok�1J
regarding the removal of any personal property or other thing of lue which any person signing below or any family
member of the deceased wishes to preserve. (awnstay nano) is not i
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 i
after cremation.
AAIMIe hereby authorize(oemetay name) /M.-'-IJ t£Gy ��Q4�'7'. �c�Fl to cremate the
rbj"bi'7
of the deceased.
FINAL DISPOSITION ••
The person authorized receive the cremated remains of the deceased from the crematory is:
I
Name:
Address: EAv A-)-J6 , Phone: 57e s'77�
The cremated remains of deceased will be disposed of as follows:
If for any reason a person named above does not take possession of the cremated remains,
(oemelory name) r y L yiL r"'l�L f7�9 h?�tL�'�( is authorized to give possession of the remains to
(funeral home name) � �f s%/�C�,r.''t' by delivery in person or by registered mail.
WE
i
DOS-1898-f-I (Rev.01/10) Name of Dsomsed Page 2 of 3
I
( the following)
un UWe nd that if the remains are not claimed within 120 days of cremation,
,( name) g c£ri ('Q f r7 ?c w,`1 may dispose of the remains in an Irretrievable manner,
such as by scattering.
CREIIILATION CONTAINERIURN_.
(/ ONE of the following)
An um to be used as a container for the cremated remains has been purchased from
and is described as follows:
I/We understand that if the um is too small to hold the entire cremated remains,an additional rigid container may be
used for delivery.
An um s not yet been purchased. IMIe understand that if no um is purchased or otherwise provided
(womatonr name) rti z �, �,� C',% ,�r3 12 c u�� will place the cremated remains in a rigid temporary
container for delivery.
This Authorization Form was providedby(trmerst&eaorrr�neJ
was executed at(runerel hame name) '
(runeraihomeaddress) 1'?.< 41.,g�,�,Q£,U ��4/v5 ; cs 5� /.1d� 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 pen;on(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.
r•G
Sign is day of
Typed or PMed Neme on:
A
Typed cw Panted Name Sipnaitrre
Address
Typed or Printed Name ^e
Address
WITNESS* /
Funeral Director typed or Name
/17
� �7y
RggmWW Number
of Dsoemd Pep UM or 3