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f ami we are the person(s)hawing priority under Public Heath Law section 4201 and have the right to authorize
Oren**on of the remains of the deceased. My►Mur rela#>i xwWV to the deceased is as fol*a+ns:
Nwr�b —rDescnpbon-
A person designated its writing pursuant to Public on 4201 (3);
z The surviving spouse:
21. The surviving doh partrw..
4Any surviving child e#ikew years of age or older:
4. A surviving parent.
S.A surviving sibling eighteen years of age or okMr,
6. A lawfully appokited guardian,
7-Any person(s)eighteen years of age or oiler entitled to share in the estate and who Ware closest in
relationship to the deceased;
S. A duly appo"ed fiduciary of the estate;
S. A dose friend or relative who has executed a written statement pursuant to Public Health Law;4201 f 71,
10A cif fiscal officer of a count or a public admk*.&a or appoinled pint to the Surrogates Court
Procedure Act
10a.Any other person who is acing on behalf of the deceased and who has executed a written ant
pursuant to Pr ilic Health Law F 4201(7).
as AU i 4REE of the(r*xvin-W
;'i VWe hereby affirm that the body of the deceased does not contain a battery, battery pack, power caeN.
radioactive implant,or radioactive device and that any such materials were removed prior to the execubon of this
Auftwrzation Forrrv. Fadure to narnove Unse trouts prior to c»nuffion may result in harm to the crornatory and
cr+eranatoKy personnel.
�rarr , � 10 59 regard
VV41e hereby affirm that rr►sb'ucbons have been given to rim&=w
the removal of arty personal property or other thing of value which any person signing below or any family member of the
deceased washes to preserve ,awmoy nimm, Pam+View crematory is not amble for
removal of personal items from the containmer or from the rerrwas of the deceased. Personal item left in the contain w or
with the remains will be destroyed by the cnmwt m pr+oca m and cannot be reb eved otter cremation.
UWe her*W autlrorim(awnawy t4 cremate the
remins of the wed.
FML DWOIIQSiT QN
The person authorized to receive the crWM4ed remains of the deceased from the aerrnartory is:
Narrve: FUN91 Hgm P
I
Address? 11 Lafayette 99MAUM New York 12804 Phone: (518)761-920
The crerrutted remains of deceased wilt be disposed of as foliows:
Return to family to be decided
If for any reason the person named above does not take lion of the crematbd rein ft. j
ftVWr*rwr n onW Pine View CremadotY v� is authorized to give possession of the remains to
rror Bakes Funeral titxrle by day in person or by r+egrsWed read.
UMbW they k dowtaiO
llVVe wderstand that if the remains are not Claimed within 120 days of aernation.
(awmawy may dispose of the remains in an are waW rrtanner,
such as by scattering
1Lf a�ONE of the foAmvino
An tun to be used as a cordasrw for the cremated remains has been purchased from
Baker Funeral Home and is described as follows.
INVe urKkwstand that if the um is too small to hold the erttir+a aemated remains,an additional rifted caa ntatner may be used
for de lkwy.
-OR-
An urn has not yet been puuchased, ttvtte underfed that it no tun is purchased or otherwise provided
1 , .vey name# Puce View CretnaM vAI place the cremaIAd remains in a rigid temporary
contakw for delivery.
This Authonzzbon Form was providers by tamdnc*or sys s>t►t ,,, �}ce�r#14159
was executed at tr*ww twoF t
(aufxvw Mr*addVeW I afthafte StrP& __and is sited by the fut>,eral director
as witness to ds execution
UWe have mowed a completed copy of this Authormabon Form.
Ttw person(s)kk"tW*d befog istme the person(s) in coftol of dispoeMon,who by signing this Authorization
Form,a#test(s)to the accuracy and completenwe of the Worrnabon cof tained in this Authorization Form and
authortze(s)the foregoing.
.n A '
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veacr
Funeral Home Reg.#01130