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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 ------- - i ---------------------------------------------- -------------------- . it Remarks --------------------- I �. i Male ---------------------------------- ------ Move--------- I Place of Death________ ��r��---- ��5----��5 t5 ----------------------------------- Estimated Weight of Remains and Container_____________150 _JL---_-_--_----__--- I 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 i i 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)