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New York State
Department of State
NEW YORK DIVISION OF CEMETERIES
Division of One Commerce Plaza
STATE OF 99 Washington Avenue
OPPORTUNITY. Cemeteries Albany,NY 12231-0001
ies
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.
4/18/2019 Number: A
Date:
Crematory Name: Pine View Crematory
518-745-4477
Quaker Road,Queensbury, NY 12804 Phone:
Address:
iere
rwhich
ATION IS AN IRREVERSIBLE AND FINAL PROCESS. s into a cremation chamber where
tion is carried out by placing the nd Hamelns of Thethe deceased and he t and flame will inc incinerate an container d consume everything except bone and metal,
ding the remain
e subjected to intense heat a
are all that will be left after cremation.
Following cremation,the crematory dust and will
residue will fkelyl be left behind. The Icematory wall separate incidental nc dental and foreign rmater al from
chamber, but some minima remains
the remains and the incidental and foreignnto a material
designated conill be tainer or umosed of as f eCremated remains generaquired by law. The lly are pulverr ied unt I nol be
y
pulverized into small pieces and placed
single fragment is recognizable as skeletal tissue.
m the
OPENING OF THE CONTAINER
The crematory may only opt n the co that nohmater alris enclosed which e un-cremated umight injurman ie employees cor damage the crematory property. If
identity of the deceased or
the
human remains are deliverein emains be moved into a such is not itable container before it accepts he remains.itable for cremation such as ceremonial or nThe opental ing of a
crematory will require that toasuitable
before a witness and will be done in privacy,with dignity and respect.
container or the transfer or removal of remains will be conducted
IDENTIFICATION OF DECEASED
Name of Deceased:
Richard Birkhan Marital Status:
282 Gailey Hill Rd., Lake Luzerne, NY 12846
Last Known Address:
jPlace of Death: residence —7
55 DOB: �' 1' � �l!z�Date of Death:4/17/2019 Estimated Weight: 175# j
Sex: ❑M ❑ F Age:
Description of casket/container in which remains will be delivered.
MacDonald Container basic cardboard with reinforced wood bottom
PERSON IN CONTROL OF DISPOSITION
(Person(s)in control of disposition, initial ONE of the following) j
signated in a will or written instrument executed pursuant to Public
I am/We are the designated agent of the deceased de
Health Law Section 4201.
O
I/We have no knowledge that the deceased remains executed
and rift are the person(s)son(s)having prion instrument pursuant to r it ic Hunder Public Health Law Law Section 4201 or a
will containing directions for the disposition of his or h
Section 4201 and have the right to authorize cremation of the remains of the deceased. My/Our relationship to the deceased is as
follows: Richard Birkhan
(Name of Deceased)
Page 1 of 3
DOS-1898-f(Rev. 08/15)
i
A,uthotFization for Cremation and Disposition
(Insert from the list below)
Number: 5 Description:
sister
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
a county executed publ cadministrat a written ortappoin appointed pursuanement pursuant to t Public
lhe Surlogate's Coulrt Procedure Act;
10. A chief fiscal officer o Y
deceased and who has executed a written statement pursuant to Public Health
10a. Any other person who is acting on behalf of the
Law Section 4201(7).
flniti&fALL THREE of the following)
eceased does not contain a battery, battery pack, power cell, radioactive implant,
I/We hereby affirm that the body of the d
re removed prior to the execution of this Authorization Form. Failure to remove
or radioactive device and that any such materials we
these items prior to cremation may result in harm to the crematory and crematory personnel.
Patricia Miller
/�L 12 1
iMe affirm that instructions have been given to (Funeral Director Name)
I of an personal property or other thing of value which any person signing below or any family member of the
regarding the remova Y p
Pine View Crematory
deceased wishes to preserve. (Crematory Name)
is not responsible for the 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.
Pine View Crematory
I/We hereby authorize (Crematory Name)
to cremate the remains of the deceased.
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Brewer Funeral Home, Inc. representitive
Name: 518-696-2744
Address:
24 Church St., Lake Luzerne, NY 12846 Phone:
�
The cremated remains of deceased will be disposed of as follows:
burial in Luzerne Cemetery
If for any reason the person named above does not take possession of the cremated remains,
is authorized to give possession of
Pine View Crematory
(Crematory Name)
by delivery
the remains to Brewer Funeral Home, Inc.
(Funeral Home Name)
in person or by registered mail. Richard Birkhan
(Name of Deceased)
Page 2 of 3 jl
DOS-1898-f(Rev. 08115)
i4uth6frization for Cremation and Disposition
(Ini"al the following)
I/We understand that if the remains are not claimed within 120 days of cremation,
Pine View Crematory
may dispose of the remains in
(Name of Crematory)
an irretrievable manner, such as by scattering.
CREMATION CONTAINER/URN
0111 "SWO9k
An urn to be used as a container for the cremated remains has been purchased from Brewer Funeral Home, Inc.
and is described 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-
An urn is not yet purchased. I/We understand that if no urn is purchased or otherwise provided
Pine View Crematory
will place the cremated remains in
(Name of Crematory)
a rigid temporary container for delivery.
This Authorization Form was provided by Patricia Miller was executed at
(Funeral Director Name)
Brewer Funeral Home, Inc.
(Funeral Home Name)
24 Church St., Lake Luzerne, NY 12846.
(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 is/are the person(s)in control of disposition,who by signing this Authorization Form,attest(s)
to the accuracy and completeness of the information contained in this Authorization Form and authorize(s)the foregoing.
Signed this 19 day of April 20 19
Typed or Printed Name
Gli3�
Ad ress
Typed or Printed Name Signature
Address
Typed or Printed Name Signature
Address
WITNESS:
Patricia Miller
(Funeral Director Typed or Printed Name) (Funeral Director Signature)
12465
(Registration Number)
Richard Birkhan
(Name of Deceased)
DOS-1898-f(Rev. 08/15) Page 3 of 3