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NYS Department of State
k;Ithorization for Cremation and Disposition Division of Cemeteries
One Commerce Plaza,99 Washington Avenue
Albany,NY 12231
(518)474-6226
www.dos.ny.us
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date: 41 -a" I 1 Number: a H
Crematory Name: Pine View Crematory
Address: Quaker Road, Queensbury, New York 12804 Phone: (518)745-4477
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 heatand 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 an 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: A act/ias raworc-4zkMarital Status: w
Last Known Address: Zj(J l a
Place of Death:l� l Q �Q� �;�T C1 f,l�C Q9�.o YG�r�C � /V Y/Z2-d
Sex: 10 OF Age:q DOB: lZ (o Z LP Date of Death: �V ( Estimated Weight:
Description of casket/container in which remains will be delivered:
Corrugated Cardboard Box with Plywood Starmark Model #38808
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.
-OR-
11j WVe have no knowledge that the deceased executed a written instrument pursuant to Public Health Law
s section 4201 or a will containing directions for the disposition of his or her remains and (Continued nextpage)
A. (—a-nwro- ,,s
DOS-18984-1 (Rev. 12/11) Name of Deceased Page 1 of
I am/we are the person(s) having priority under Public Health Law section 4201 and have the right to au
cremation of the remains of the deceased. My/Our relationship to the deceased is as follows: thorize
(Insert from the list below)
Number: 2—Description: /J
A person designated in writing pursuant to Public Health Law section 4201 (3);
2. The surviving spouse;
2a.The surviving domestic partner;
OAny 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;
1Oa.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).
(Initial ALL THREE of the following)
�7 I/We hereby affirm that the body of the deceased does not contain a battery, batterypack, ow
er radioactive implant, or radioactive device and that any such materials were removed prior tot a execution of thisl
Authorization Form. Failure to remove these items prior to cremation may result in harm to the crematory and
crematory personnel.
INVe hereby affirm that instructions have been given to(funerei director name) Starr Baker #10159 regarding
Ite 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. (crematory name)__ 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(crematoryname) Pine View Crematory to cremate the
remains of the deceased.
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Vame: Baker Funeral Home Personnel
Address: 11 Lafayette Street, Queensburv. New York 12804 Phone: (518) 761-9303
The cremated remains of deceased will be disposed of as follows:
Return to family to be decided
'for any reason the person named above does not take possession of the cremated remains,
mmatoryname) Pine View Crematory is authorized to give possession of the remains to
unerat home name) Baker Funeral Home by delivery in person or by registered mail.
_. __ D..nnOnIrl
r
e
tth=nderstand
that if the remains are not claimed within 120 days of cremation,
(crematoryname) Pine View Cremato
such as by scattering. may dispose of the remains in an irretrievable manner,
CREMATION CONTAINER/URN
Initial ONE of the following)
An urn to be used as a container for the cremated remains has been purchased from
Barer Funeral Home 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
-OR-
_�.k_An um has not yet been purchased. I/We understand
(crematory name) Pine View Cremato that if no urn is purchased or otherwise provided
container for delivery. will place the cremated remains in a rigid temporary
This Authorization Form was provided by(funeral director name)
was executed at(funeral home name) Starr Baker#10159
(funeral home address) 11 La Baker ette Street Queensbu New York 12g04l Home
as witness to its execution. and is signed by the funeral director
'/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
:orm,attest(s)to the accuracy and completeness of the information contained In this Authorization Form and
iuthorize(s)the foregoing.
ligned this day of 20
ryped or Panted Name
Signature
u r
iddraw
'yped or Printed Name
Signature
duress
yped or Printed Name Signature
tdress
ITNESS:
Starr Baker
mere/Director Typed or Rkftd Hlame Funeral Di nature
Funeral Home Reg.*01130
3gistration Number (n� f