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Authorization for Cremation and Disposition NYS Department of State
Division of Cemeteries
One Commerce Plaza,99 Washington Avenue
Albany,NY 12231
(518)474-6226
www,dos.state.ny.us
This Authorization Form must he completed and signed prior to delivery of remains for cremation.
Date: y— Number:
Crematory Name: Pine View Crematorium
Address: Quaker Road, Queensbury,NY 12804 Phone: 54 74 S
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 he 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 th 3 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 DECEAS ?
Name of Deceased: C4--o C, IL/ O e_ Marital Status:
Last Known Address: L epo u-Vq. ,,4 )4
Place of Death: ffoi'ly l 0& 5wit 4a-
Sex: M Age: D01 2j Date of Death Estimated Weight:
Description of casket/container in which remains will be delivered:
0 U flews C✓�✓ [prr'1 S _ C �c Ia�
PERSON IN CONTROL OF DISPOSITION
(Person(s) in control of disposition, initial ONE of the follow ng)
I am/We are the designated agent of the dE ceased designated in a will or written instrument executed
pursuant to Public Health Law section 4201.
-
I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law
se tion 4201 or a will containing directions for the dis osition of his or her remains and (Continued next page)
DOS-1898-f-I(Rev. 01/10) Name of Deceased Page 1 of 3
I am/we are the person(s) having priority under Pub is 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; Q
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 orolder;
4. A surviving parent;
5. A surviving sibling eighteen years of age or c Ider;
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;
8. A duly appointed fiduciary of the estate;
9. A close friend or relative who has executed za 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 LL THREE of the following)
INVe 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.
RJ
__��1NVe hereby affirm that instructions have een given to (funeral directorname)
l G �
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. (crem itoryname) 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.
Me hereby authorize (crematoryname) Pine View Crematory 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: Carleton Funeral Home., Inc.
Address: 68 Main Street,Hudson Falls,NY 12839 Phone: 518-747-4243
The cremated remains of deceased will be disposed of as follows:
�C-) 9s SYU
v
If for any reason the person named above does not take possession of the dremated remains,
(crematoryname) Pine View Crematory is authorized to give possession of the remains to
(funeral home name) Carleton Funeral Home,Inc. by delivery in person or by registered mail.
l/, Vey ec
... Name of Deceased Page 2 of 3
(Initial the following)
INVe understand that if the remains are no claimed within 120 days of cremation,
(crematory name) Pine View Crematorium 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 c emated remains has been purchased from
—Carleton Funeral Home, Inc.. anc is described as follows:
INVe understand that if the urn is too small to hold tie entire cremated remains, an additional rigid container may be
used for delivery.
-OR-
An urn has not yet been purchased. INVE understand that if no urn is purchased or otherwise provided
(crematory name) will place the cremated remains in a rigid temporary
container for delivery.
The Authorization Form was provided by (funeral direc or name) ��./� VO IJI -e k
was executed at (funeral home name) Carleton Funeral Home, Inc.
(funeral home address) 68 Main Street, HudsOIL Falls,NY 12839 and is signed by the funeral director
as witness to its execution.
INVe have received a completed copy of this Autho ization Form.
The person(s) identified below istare the perso (s) in control of disposition, who by signing this
Authorization Form, attest(s) to the accuracy ar d completeness of the information contained in this
Authorization Form and authorize(s) the foregoing,Signed this 1-7.� day of , 201
t .
r4vn .1 r' 414
Typed or Printed Nam Signature
1-( Q'%' tat e- a l evil Put
Address
Typed or Printed Name Signature
Address
Typed or Printed Name Signature
Address
WITNESS:
Q- I !�A - �a . A
Fu e i ctor Typed brPr0ed Name Funeral Director Signature
0a
Registration Numbed
DOS-1898-f-I(Rev.01110) Name of Deceased Page 3 of 3