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New York State
r Department of State
NEW YORK Division of DIVISION OF CEMETERIES
STATE OF One Commerce Plaza
OPPORTUNITY. Cemeteries 99 Washington Avenue
_ Albany,NY 12231-0001
Telephone:(518)474-6226
www.dos.ny.gov
Authorization for Cremation and Disposition
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date: 04/14/2019 Number: "Z
Crematory Name: Pine View Crematory
Address: Q,.t #4&44t-!-y yuy l 29)6�1 Phone: S r$ 7 y5-1-/y7-7
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.
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 urn. Cremated remains generally are pulverized until no
single fragment is recognizable as skeletal tissue.
OPENING OF THE 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 the crematory property. If
human remains are delivered in a container which is not suitable for cremation such as 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: Carolyn Lee Pittenturf Q Marital Status:
Last Known Address: I\cT--) vc'c \ ` ` C-1
Place of Death: Glens Falls Hospital
Sex: ❑M ® F Age: l� DOB: `t� Date of Death: 04/13/2019 Estimated Weight: I I�
Description of casket/container in which remains Will be delivered. 1 n
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.
R-
( age
I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
11 conta' ing directions for the disposition of his or her remains and I/we are the person(s) having priority under Public Health Law
cti 4201 and have the right to authorize cremation of the remains of the deceased. My/Our relationship to the deceased is as
follows:
Carolyn Lee Pittenturf
(Name of Deceased)
DOS-1898-f(Rev. 08/15) Page 1 of 3
Authorization for Cremation and Disposition
(Insert from the list below)
Number: 3 Description:Surviving child
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 state and who is/are closest in relationship to the deceased;
B. A duly appointed fiduciary of the estate;
9. A close friend or relative who has executed a written statement puns ant to Public Health Law Section 4201(7);
10. A chief fiscal officer of a county or a public administrator appointed ursuant to the Surrogate's Court Procedure Act;
10a. Any other person who is acting on behalf of the deceased and who as executed a written statement pursuant to Public Health
Law Section 4201(7).
itial ALL 'THREE of the following)
ECG We hereby affirm that the body of the deceased does not con ain a battery, battery pack, power cell, radioactive implant,
``er.radr6active device and that any such materials were removed prior to th execution of this Authorization Form. Failure to remove
the ems prior to cremation may result in harm to the crematory an crematory personnel.
I/We affirm that instructions have been given to Robert Barbieri
(Funeral Director Name)
regarding the removal of any personal prope or�other
7thig ofi,value whidh any person signing below or any family member of the
deceased wishes to preserve. r �"� aLJ
(G tay Name)
is not responsible for the removal of personal items from the container or f om the remains of the deceased. Personal items left in the
ain or with the remains will be destroyed by the cremation process and cannot be retrieved after cremation.
Q � IWe hereby authorize
(Crematory Name)
to cremate the remains of the deceased.
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased f om the crematory is:
Name: Regan Denny Stafford Funeral Home, Robert Barbieri
Address: 53 Quaker Road, Queensbury, NY 1280 Phone: (518) 792-1114
The cremated remains of deceased will be disposed of as follows:
If for any reas he person named above does not take p session of thi'cremated remains,
(1�� ` is authorized to give possession of
(Gematory Name)
the remains to Regan Denny Stafford F neral Home by delivery
(Funeral Home Name)
in person or by registered mail.
Carolyn Lee Pittenturf
(Name oI Deceased)
DOS-1898-f(Rev. 08/15) Page 2 of 3
l Authorization for Cremation and Disposition
itial the following)
e understand that if th mains1arJe not Maimed within 120 ays of cremation,
v may dispose of the remains in
(Name of Crematory)
an irretrievable manner, such as by scattering.
ON CONTAINERIURN
Initial ON of the following)
Regan Denny Stafford
c e n urn to be used as a container for the cremated remains has been purchased from Wmmm
and is d cribed 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-
-7 An urn is not yet purchased. IMe understand that if no urn is purchased or otherwise provided
AAwill place the cremated remains in
(Name of Crematory)
a rigid temporary container for delivery.
This Authorization Form was provided by R bert Barbieri was executed at
(Furm V Director Name)
Regan Denny Stafford Funeral Home
(Funeral Home Name)
53 Quaker Road, Queens bury, NY 12804
(Funeral Home Address)
and is signed by the funeral director as witness to its execution.
I/We have received a completed copy of this Authorization Form.
The person(s) identified below islare the person(s)in control of dispoisition,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.
Signed this 14th day of April 19
Jason David Carbona-Cole
Typed or Printed Name
1155 Farley Rd., Hudson Falls, NY 12839-
Address
Typed or Printed Name Signatu
Address
Typed or Printed Neme Signature
Address
WITNESS:
Robert Barbieri
(Funeral Director Typed or Printed Name) (Funw4Nrector S'nature
10185
(Registration Number)
Carolyn Lee Pittenturf
(Name of Deceased)
DOS-1898-f(Rev. 08/15) Page 3 of 3