Henderson, Carol l'itt� /ic�t C;c:tttcc.cry & Crct„;ttoriut,�
��t.t;tl:er Rol-ld
(. Uccttsbury, IVY 12804
(; 18) or (,i l t�) I<(:i-�(•<I.7(i
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From: 04/30/2019 13:41 #626 P_012/017
r
New York State
Del",bommi of Side
NEW PORK Division of avfsro
STATE OF
OPPORTUNITY Cemeteries One Commerce Plaza
99 Washington Avenue
Albany,NY 12231-DOOI
Telephone:(51a)4746226
www.des.ny.gov
Authorization for Cremation and Disposition
This Authorizst/on Form must be completed and signed prior to delivery of remains for cremation.
Date: 04/29/2019 _ Number.,_ __ __�
Crematory Name: Pine View Crematorium
Address: 51 Quaker Road,Queensbury, NY 12804 Phone. (518)745-4477
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
1 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 vA be disposed of as required by law. The cremated remains wig be mechanically
pulverized into small pieces and placed into a designated container or um. Cremated remains generally are pulverized until no
i single fragment is recognizable as skeletal tissue.
OPgiiIING OF THE 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 night injure employees or damage the crematory property. It
human remains are delivered in a container which Is not suitable for cremation such as 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: Carol Henderson Marital Status. Divorced
Last known Address: 188 Pitcher Road,Queensbu% NY 12804
Place of Death: , 55 Main St..Queensbu ,NY 12804
Sex: 0 M ®F Age: 90 DOB: 11/02/1928 Date of Death: 04/28/2019 Estimated Wei t i l6
Description of casket/container in which remains will be delivered.
Corrugated cardboard 90{WA f
PERSON IN CONTROL OF DISPOSITION
(Person(s)An control of disposition,initial ONE of Um fbllawoV)
i amNUe are the designated agent of the deceased designatedin a will or written instrument executed pursuant to Public
Hea 'on 4201.
jm?, IMIe e no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
will containing dir .ons for the disposition of his or her remains and It"are the person(s)having priority under Public Health Law
Section 4201 a have the right to authorize cremation of the remains of the deceased. My/Our relationship to the deceased is as
follows:
Carol Henderson
rnr�.d 1
I
DOS-1898-f(Rev.08115) Page 1 of 3
` I
From: 04/30/2019 13-42 *626 P_013/017
Authorization for Cremation and Disposition
(Insert from the list below)
Number: 3 Description:Child
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;
S. A surviving sibling eighteen years of age or older;
e. 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;
S. A duly appointed fiduciary of the estate;
9. A dose friend or relative who has executed a written statement pursuant to Public Health Law Section 4201(7),
10. A chief fiscal officer of a county or a public administrator appointed pursuant to the Sur►ogate's Court Procedure Act;
10a. A other person who is acting on behalf of the deceased and who has executed a written statement pursuant to Public Health
aw 'on 4201(7).
(Inds/ALL 7HR of the following) itain
4aaftery,
� /'\_--__--_ INVe ereby afirm that the body of the deceased do not battery peck,power cell��trfar�choay�a6'veCi4mJ�plaLnt,
radio evice and that any such materials were removed prior to the execution of this AUMMzation Form Failure to remove
items to cremation may result in harm to the crematory and crematory personnel.
l
IMP. INVe rm that instructions have been given to _ Cassldy VonStettina
(FwwtlOMOWiaam)
r arding th oval of any personal property or other thing of value which any person signing below or any family member of the
deceased wishes to preserve. Pine View Crematorium
r�»iar+�.i
is as
ible for the removal of personal items from the container or from the remains of the deceased. Personal items left in the
L,contel:r or th the remains will be destroyed by the cremation process and cannot be retrieved after cremation.
i��ttw herebysuthwize Pine View Crematorium
raw,.vyNamai
m remains of the deceased.
FINAL_DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name: Regan Denny Stafford Funeral Home,Cassidy VonStettina
Address. 53 Quaker Road,Queensbury, NY 12804_ Phone (518)792-1114
The cremated remains of deceased will be disposed of as follows
Retum to family
If for any reason the person named above does not take possession of the cremated remains.
Pine View Crematorium �T_is authorized to give possession of
the remains to Regan Denny Stafford Funeral Home by delivery
rF,,,�.«rairerw,�y
in person or by registered mail
I
Carol Henderson
----- (Na"Of ascaaaal
I
DOS-1898-f(Rev.08/15) Page 2 of 3
From: 04/30/2010 13:42 OZ25 "P_014/017
r
Authorization for Cremation and Disposition
Virtble
►g)
understand that if the remains are not claimed within 120 days of cremation,
Pine View Crematorium may dispose of the remains in
rNapnearC�enpue�Y/
anner.such as by scatteringTAINERRIRN
tandisedescribe
or fbNowir� Regan Denny Stafford
An to be used as a container for the cremated remains has been purchased from asfollows:nd that if the urn is too s n to hold the entire cremated re ns,an additional rigid container may be used for delivery.
-OR-
An um is not yet purchased. IM/e understand that if no um is purchased or otherwise provided
Pine View Crematorium will place the cremated remains in
(AW-OfC-1ay)
a rigid temporary container for delivery
This Authorization Form was provided by Cassidy VonStettina _ was executed at
(Fumww D cw AAww)
Regan Denny Stafford Funeral Home
(Arend Hoop.Abm)
53 Quaker Road,Queensbury,NY 12804
(AO,nd Hope Addeo)
and is signed by the funeral director as witness to its execution.
Me have received a completed copy of this Autirorization Form.
The person(s)identified below islare the persons)In control of dispositon,who by signing this Authorization Form,attesgs)
to the accuracy and completeness of the irdormation contained In this Authorization Form and authorize(s)the foregoing.
Signed this__29th day of April 19
Thomas Henderson
Ir
ypaerr+rwadewr,e
8297 Quail Meadow Way,West Palm Beach,FL 334 -
u
Typed of Fr~AfWW—__—_�-----
Addws ---------
VNTNESS:
Cassidy VonStettina
/Foetid arecW Typed or RYmbd Nang/ ( iecim SW tM)
13709
fflba
Carol Henderson
rNnppe d/OUMseej
DOS-1898-f(Rev.08/15) Page 3 of 3