Jensen, Susan Pixie View Cemetery& Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
Funeral Home _-___
Requested Return Tune----------
Name---------- j`-1__�1`�--------------------Case No. -----------V -------
Date of Cremation__-- (1l__rl'inie Started---I l_50Tilne Completed
Placedin Hold: -----------------
Placed in Refrigeration: -------------
Placed in Retort:
Type of Container -------
-
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----------------------------------------------
-------------------- .
it
Remarks ---------------------
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�.
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Male ---------------------------------- ------ Move---------
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Place of Death________
��r��---- ��5----��5 t5 -----------------------------------
Estimated Weight of Remains and Container_____________150 _JL---_-_--_----__---
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Date &Time Remains arrived at Crematory---------------IIA,�I-----INh--------
Nl —
Name of Funeral Director or Registered Resident Delivering ReIIlains____ M — --
Detailed reason for
delayif rem m
ains were creniated ore than 48 hours from time of accepted
delivery
----------------------------------------------------------------
------------------------------------------------------------------------
Retort Number in which Remains were cremated-------------- _ -!�=_--_-_--
Note: The Cremation Log shall be retained in the Permanent File of the Crematory
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NYS Department of State
Division of Cemeteries
Authorization for Cremation and Disposition One 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.
-� ) 3
Date:
l��� — Number: � - �!�0
l�U� ,�� Jac
Crematory Name: G `� -•--
Address: t
dG a Qf�
Phone:
CREMATION IS AN IRREVER BLE 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 um. Cremated remains generally are pulverized until no single fragment is
recognizable as skeletal tissue.
OPENINr 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 wh
ich might injure employees or
damage crematory property. If human remains aradoelivwelrledenuire t at'the rener hmahns be moved into a is not suitable for suitablen
such as a ceremonial or rental casket, the crem ry q
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.
r
IDENTIFICATION OF DECEASED
Marital Status: el4e
�
Name of Deceased: t�Cl/�
Last Knownt dd ss: La
OIL"o-f(Death:
/
Sex: ❑M Age: DOB:
Date of Death: � Estimated Weight:
_�
Description of casket/container in which reglains will be delivered:
PERSON IN CONTROL OF DISPOSITION
et s)in control of disposition,in"ONE of the following)
I am/We are the designated agent of the deceased designated in a will or written instrument executed
g�frsuant-to Public Health Law section 4201.
-OR-
I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law
section 4201 or a will containing directions for the disposition of his or her remains and (Continued next page)
Page 1 of 3
DOS-1898-f-I (Rev.01/10)
Name of Deceased
c Health Law section 4201 and have the
am/we are the person(s) having priority under
Our'relationship to the deceased is as follows:
to authorize
cremation of the remains of the deceased. y
(Insert from the list below)
Number: Description: S2 `
1.A person designated in writin 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 tiA' THREE of the following)
e hereby affirm that the body of the deceased does not contain a battery, battery pack, power cell,
radio i'a implant, or radioactive device and that any such materials were removed prior to the execution of this
Auth r tion Form. Failure to remove these items prior to cremation may result in harm to the cre atory and
cr personnel.
�� i
/We hereby affirm that instructions have been given to (funeral director name)
regardi the removal of any personal property or other thing o va ue whi�h,,aray ers�n signing zbeAaw orrany family
X �J G✓ C.�'L< is not
mtber of the deceased wishes to preserve. (crematory name) %h onal items
responsible for removal of personal items from the container or from the remains of the deceased. ers
destroyed by the cremation process and cannot be retrieved
left in the container or with the remains will be
a "rem ion. c
-IWek hereby authorize (crematoryname)
to cremate the
I
r ainst'of the deceased.
I
FINAL DISPOSITION
The person authorized to recei a the cre ted remains!a deceased from the crematory is:
Name:,,, �-
/) Phone:
Address: /"
cremated remains of deceased will be disposed of as follows: ICY n
The crem
_ I
V f d v�� lilt ,,4
� I
If for any reason the pets n name a ve does p A4ake possession of the cremated remains,
(crematory name) / /�' '7 is authorized to give possession of the remains to
( ry by delivery in person or registered mail. j
(funeral home name
Name of Deceased
Page 2
DOS-1898-f-I (Rev.01/10)
R
(lni ' th following)
I/WeXueand at ith re sins f laimed winhay dspose of the20 days of remains in an irretrievable manner,
Acramry name)such as by sc
CREMATION CONTAINERlURN
(I i i I 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 additional rigid container may be
Vforof et been urchased. Me understand that if no urn is purchased or otherwise providedn urn has n y will place the cremated remains in a rigid temp ry
e) 'f
container for delivery. �—
..�.
This Authorization Form was provi d b (funeral director e
was executed at(funerq(hoepe name G�r d and is signed by the funeral director
(funeral home address) `f
as witness to its execution. % I
I/We have received a completed copy of this Authorization Form.
The person(s) identified below islare 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.
day of � ' � ° 20
Signed t is _ y
Sigrptwe
Typed o nted N �j / A /
Addr s
Signature
Typed or Printed Name
Address
Typed or Printed Name Signature
Address
WI ESS:
IN, ral Direct S' natur
Funeral Director Ty ed or Printed Name
/;a 3 :0�
Registration Number
� �/7
Name of Deceased
' Page 3 of 3
DOS-1898-f-I (Rev.01/10)