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NYS Department of State
Authorization for Cremation and Disposition U"On of cerneteries
one Commerce Plaza,gg Washington Avenue
Albany,NY 12231
(518)474-6226
www.dos.state.ny.us
This Authorization Form must be completed and sigaed prior to delivery of remains for cremation.
Date: Number:
Crematory Name: ,U
Address: aP /v ' Rhone: �(�?y� 7
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.
sonable efforts to remove all of the remains and other material from
Following cremation,the crematory will take rea
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
Fecognizable 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
Marital Status: C(1
Name of Deceased: 44 R
�'� e
Last Known Address:
Place of Death:
-- Date of Death: Estimate�Weig�ht:
/
Sex: ❑M �F Age: �f DOB: / /
Description of casket/container in which remains will be delivered:
Ob&;1241`1 �Q
Pl;�RSON IN CONTROL OF DISPOSITION
(Person(s) In control of disposition,kM 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-
_ uted a written instrument pursuant to Public Health Law
I/We have no knowledge that the deceased exec
section 4201 or a will containing directions for the disposition of his or her remains and
(continuede xt Me)
'4
Name of Deceased Page 1 of 3
DOS-18g8 N (Rev.01110)
I ami 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 llst below)
Number: Description: ,OAc F d -
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;
6.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).
(ftj!W ALL THREE of the following)
_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.
_I/We hereby affirm that instructions have been given to(lunaraldbedorname) b9i lJ l�o.�6T
regarding the removal of any personal property or other thing of�;�'lue which any person signing below or an family
member of the deceased wishes to preserve. (awnatay name) / i�U D!f q) t '4��<<` 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(aemataYna W) 1DU ! A�Z•4 to cremate the
remains of the deceased.
FINAL DISPOSITION
The person a orized t74,OA
a the cremated remains of the deceased from the crematory is:
Name: ff7r—
Address:� G�
�� Phonel37�
The cremated remains of deceased will be disposed of as follows:
WIC VL-C e-Ite-A b /t-6-0,1
If for any reason person named above does not take possession of the cremated remains,
(crematory name) / !�� f is authorized to give possession of the remains to
(funeral hane name) by delivery in person or by registered mail.
BIWNA /� Niel
Page 2 of 3
DOS-18Wf4 (Rev.01110) rJarne of Dwwwd
b ,
•
(h"the following)
INVe un rstand that�theremains are n�claiffithin 120 days of cremation,
,,�j ZyiL;I`1�A7?Sf� �ied
may dispose of the remains in an irretrievable manner,
such as by scattering.
CREMATION CONTAINERIURN
(J,aft 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:
INVe 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 has not yet been purchased. Me understand that if no um is purchased or otherwise provided
(crematory name) J,,�,�J tt cLj ��Tb 0/c.�Dyr will place the cremated remains in a rigid temporary
container for delivery.
This Authorization Form was provi y(funeral*amr
H.1A /J
was executed at(runerel home rnamel '
(f�nww home ad ) ,9 J5jU& is signed by the funeral director
as witness to its execution.
INVe have received a completed copy of this Authorization Form.
The person(s)identified below Ware the person(s)in control of disposition,who by signing this
Authorization Fonn,aft st(s)to the accuracy and completeness of the information contained in this
Authorization Form and authorize(s)the foregoing.
day of
3i ned this _C _ .n
ra
'-j _
& v
Typed or Printed I ' 5� C / %o2 c� 3/
3q c+cc��c3C6- 0�
Address
Typed or Printed Name SOWUre
Address
Typed or Printed AWM SOWUM
Address
WITNESqF _,-
A
Funerai Typed or Printed Name Fun"
Rjgj&iebKNumbW
��of Doosesed Page 3 of 3
OOS-1898-f-1 (Rev.01/1a)