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NYS Department of State
Authorization for Cremation and Disposition Division of Cemeteries
One commerce Plazs,88 Washington Avenue
Albany,NY 12231
(519)474 6226
www A.Its.-Sule.ny.ua.
This Authorization Form must be completed dnd signed prior io delivery of remains for cremation.
Date:3/17/2019 Number: `"Z� 9
Crematory Name;Pine View Crematory
Addmrr,•Q11-19 :r Rowd.Otuenrhunr NY 1aflnA rnone:a lo-r.��-,��
CREMA"1ruN IS AN IRREVERS113LE AND FINAL PROCESS.
Cremation i5 rarriel pyt b plaiQin�thr. rnmAin1 f tt#go����nrpin�nni�i III ilIII IILl111111III 11h 1
.. .,,..,,.., ,.,,..., .JN l .,, �%T%l Will 1 rr son 14tnu WIII tRSIi1al18L1.....I
curtsume everriAing ek4vNl IVunc and metal. WIbuh are all t"$Will be left after r.mmalioti.
redhpwilru ut.-matlon, the croniglgly will take re1,WAIlallit r riling tr3 4Y4 911 ftl illfi rpimfill11 MIi ivhil 1urlrrl1-11 frllrn
Ilti.. tn..11u,lls IiI 1.IraurlJ0r, uut sul11V minimal num antl rasei vy will jil)VIY ,lft hrihinn 111m1 rrromtnrlr will rn�nrnin
'1$1I .�� U nO'H r rr 1,111WHY1'llYIN ME IY'.h1AI ti 1,r rr I IIOO rrle.local I JI I 1pn milwanal will 141 JI-O.ue vr.i of uu
icquired by law. i ne cremated remains will be mechanically pulverized into small piecq�alld vldcud intn a
dCdigneMr!r..rsrlta�rrCl uI will. Cremligo rtmaina ganardlhl fire VIIJUNdIrort until no Qrngle bagmant is
recogntzawe 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 oinployees 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. I"he 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.
1DENTIFICATIQN OF DECEASED
Name of Deceased:Kurt J. Locke Marital Status: Divorced
I est Known Addrecc:white 6irCh I,anP,Apt 1 ni, Indian Lake, NY 12842 ) 3a
Place of I)ARth.FIMP y od it Nui ll r rlo)uk. 112 Eld Bawl l4d., rdOAh Qtmk, NY 12653
*911r 121M Of A& 7n I)AM 111301190 Uala 8o u8dtil. C-UrrIQICU vvt:f rlt: 7 QUN
Description of casket/container in which remains will be delivered:
MacDonald Container Co. basic cardboard cremation container
PERSON IN CONTROL OF DISPOSITION j
(Person(s)in control of disposition, initial ONE of the fbilowing)
I am/We arc tho designnfnd agent or the deceased designated to a will or written 11mhument executed
pursuant to Public Health Law section 4201.
-OR-
I/We 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 (Continued next Page)
Kurt J.Locke
DOS•1898+1 (Rev.01/10) Name of Deceased Page 1 of 3 j
I
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 deceg.50d. My/0ur relatinnship to tiro deoeosed i,as
(Insert from the list below)
Number:7Description:cousin
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 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 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§4201(7).
(Initial ALL THREE of the following)
/We horahy affirm llwt ilia lindy of the rtor•eaved doac not ovniairn q h4ittoiy, Lrouray)rnrh, I11.1wer call,
r ddiutrctive 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 crq!rnatiQn may result in harm to the orolnatory and
crrmatnry rarsonnol.
� IlVlfr h�r�htr affirm llml nuihio�irn■ w� , 1. __-- v---.. t_ „�,,..,,,,,.,eY1,,,,,a,,,d,i1J �l�j'��
regarding the removal of any m-wrial gmnftrty nr nthPr thing of v9hu urhinl,nrv,i N....�albrt:•.y L..�..•• a„r la��ihr
member of the deceased wishes to preserve, (crematory name) Pine Vim Crematory is nnt;
1+0Nvr ILILIU A,r r urr,aver ar pars.,,r"i 11c1 r5 from the container or tram the remains of the
Ink Its U— „)dshsut us w`rrt ine remains Ullll be destroyed by the cr+eMation prooess and �cannot be retrieved
after cremation.
I/We hereby authorize (cremeioryname) Pine View Crematory to cremate the
femaina of the deceased.
FINAL DIS OSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name:Miller Funeral Horne
Address;6357 State Rte. 30, Indian Lake, NY 12842 Phone:518-648-0011
Thy womatful romninct of rlareasecf Will bo dioprtsrd of as I6I1,jvvs_
Return to family
It for any reason the person named above does not take possession of the cremate
Pine v d remains,
�r+�mntivy are„«f irw Crematory
1t; oUthofllt!lI115 �IIYB u�ramnr�anr rrr llrr rr•rnornv eer
wnerd Aviur nerme) Nliflv�mldl Hume �� by rloli►to
ry in pomon er b;
Kurt J Locke
OS-18984-I (Rev.0ii7o)
Name or deceased Page 2 or 3
( ilia/the following)
1/We understand that if the remains are not claim
(6remetory name) Pine View Crematory claimed within 120 days of cremation,
such as by scattering. may dispose of the remains in an irretrievable manner,
GRFJtiOYIIf1Iu rnNTnlu�Rll,Ru
( itiei ONE Of the following)
_.. An urn to t,u uuod as a container io, [lit't;lwnat&d remains nas been purchased from
and is described as follows;
,/We undarms nd that if the urn is tors small tO livid the entire cremated remains,an additional rigid container maybe
used for delivery.
-OR-
�C' 11111111111111100 An urn has not yet been purchased. I/We understand that if no um is purch
container for deli ry. ased or otherwise rovi
Icmmerory rteme) Pine View Crematory will place the cremated remains in a rigid temporary
ve
This Authorization Form was provided by(funeral director nama) Michael Miller
was executed at(Amerat*vne name)Miller Funeral Home
(funeral home address) 6357 State Rte. n tan a e,
as witness to its execution. and is signed by the funeral director
I/We have W.P.4ved a cOntNIc-tud copy of thla At.ithorization Farm,
TIw-r or,,uie(s,)Identified cwrow rnrpM the person(3)in Za,ltivl Ur disposltion,who by signing mis
Authorization Form,attests)to the accuracy and completeness of the information contained in this
Authorization Form and authorize(s)the foregoing.
Signed this— /q day of arc 20_L_9 .
Bemeice Cummins
Typed or Printed Name
PO Box 223, Blue Mountain Ike, NY 12812 �
Address
Typed or Prnted Name S/gnature
Address
Typed or Printed Name 5igrtgfure
Addross
WITNESS:
Michael Miller
Funeral Director Typed a Prnted Name Av-10-c5j-�Slgn. re
12463
Reglattetam Number
Kurt J.Locke
DOS-1898-f t (Aev.o1/1o) Name of Deceased Page 3 of 3
Cremains lkoeived By(Frint a e Si a ei rent Date Received