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)-3� NYS Department of State
Auorization for Cremation and Disposition Division of Cemeteriesone Commerce Plaza,99 Washington Avenue
►, Albany,NY 12231
(518)474-6226
www.dos.state.ny.us
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date:
3/29/2019 Number:
Crematory Name: Pine View Crematory
Quaker Road, Queensbu NY 12804 Phone:518-745-4477
Address: ry'
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 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
Name of Deceased:Marie M. Labes Marital Status:Married
Last Known Address: 138 Kickerville Lane, Long Lake, NY 12847
Place of Death:residence
60 3/22/1959 3/28/2019 350#
Sex: ®M ®F Age: DOB: Date of Death: Estimated Weight:
Description of casket/container in which remains will be delivered:
MacDonald Container Co. wood bottom cremation container
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 in&UMent eX6Wted
pUrS
ua t to Public Health Law section 4201.t7R �
"1r.4e' I/We have no knowledge that the deceased executed a written instrumentpU/SlJant10
section 4201 or a will containing directions for the disposition of his or her rem,*a1V Pl/b//�jyea ►
DOS-1898-f-I (Rev.01/10) �flne A/ 1_c
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 deceased. My/Our relationship to the deceased is as follows:
(Insert from the list below)
Number:2 Description:Spouse
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).
I
(Initial 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 (funeral director name) Michael Miller
regarding the removal of any personal property or other thing of value which any person signing below or any family
member of the deceased wishes to preserve. (crematoryname) Pine View Crematory 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.
I/We hereby authorize (crematory name) Pine View Crematory to cremate the
remains of the deceased.
I
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name:Miller Funeral Home
Address:6357 State Rte. 30, Indian Lake, NY 12842 Phone:518-648-0011
The cremated remains of deceased will be disposed of as follows:
Return to family
If for any
reason the person named above does not take possession of the crema
ted II P ed remains,
(crematory name) Pine View Crematory is authorized to give
(funeral home name) Miller Funeral Home by deli � 'X°SS1017
cos_ rY
1898-f-/ (Rev.O 1/1O) v %11
(1
rIntTial the following)
_ I/We understand that if the remains are not claimed within 120 d
(crematory name) Pine View Crematory days of cremation, ..
such as by scattering. may dispose of the remains in aR*'etrievable ma
CREMATION CONTAINER/URN
(Initial ONE of the following)
An urn to be used as a container for the cremated remains has been purchased from
and is described as follows:
I/We understand that if the urn is too small to hold the entire cremated remains, an additionl rigid container may
used for delivery. i a y be
•OR-
�An urn has not yet been purchased. I/We understand that if no urn is purchased or oth crematory name) Pine View Crematory erwise provided
will place the cremated remains in a rigid temporary
;ontainer for delivery.
"his Authorization Form was provided by (funeral directorname) Michael Miller
vas executed at(funeral home name) Miller Funeral Home
`uneral home address) 6357 State 12te. n Ian a e,
Is witness to its execution. and is signed by the funeral director
We have received a completed copy of this Authorization Form.
'he person(s) identified below is/are the person(s) in control of disposition, who by signing this
►uthorization Form, attests)to the accuracy and completeness of the information contained in this
►uthorization Form and authorize(s) the foregoing.
;igned this day of , 20�,
VVilli tabes
yped or Pmted Name Signature
PO Box 794, Long Lake, N Y 12847
Iddress
yped or Printed Name Signature
Iddress
yped or Printed Name Signature
Iddress
VITNESS:
Michael Miller
'uneral Director Typed or Printed Name lfuninil Mirector Signature
12463
iegistration Number
Marie M.Labes