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New York State
NEW YORK Department of State
Division of DIVISION OF CEMETERIES
STATE OF One Commerce Plaza
OPPORTUNITY. Cemeteries 99 Washington Avenue
Albany,NY 12231-0001
Telephone:(518)474-6226
www.dos.ny.gov
Authorization for Cremation and Disposition
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date: May 01 , 2019 Number: 300
Crematory Name: L FV:�'w Ceemba4i
`t
Address: 71 0-JwILIL (Za kp lu gf NS 8o it y 11 OD�hone:
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 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 might injure employees or damage the crematory property. If
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: Eleanor R. Clark MaritalStatu!Widowed
Last Known Address: 26 Saunders St. , Whitehall, NY. 12887
PlaceofDeath: Elderwood of North Creek, Johnsburg, NY 11113
Sex: ®M EkF Age: 8 9 DOB: Feb. 07, 1930 Date of Death: 0 5/01 /2 01 9 Estimated Weight:
Description of casket/container in which remains will be delivered. Florence Casket Co. Delux Tray
wood, wood composite base and cardboad top
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-
LV2 I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
will r_.0ntaining orectiong for the disposition of his or her remains and (/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:
Eleanor R. Clark
(Name of Deceaseco
DOS-1898-f(Rev. 08/15) Page 1 of 3
Authorization for Cremation and Disposition
(Insert from the list below)
Number:_Z Description:_
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 Section 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 Section 4201(7).
(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.
91A�—IMe affirm that instructions have been given to Bruce K. Mason
(Funeral Director Name)
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. 1 W
(Crematory Name)
is not responsible for the 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.
IMe hereby authorize �r� yx-�
(crematory Name)
to cremate the remains of the deceased.
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name: Bruce K. Mason
Address: P.O. Box 277, Fort Ann, NY. 12827 Phone: 518-639-5252
The cremated remains of deceased will be disposed of as follows:
Return to family for burial.
If for any reason the person named above does not take possession of the cremated remains,
rig EU,ZfLj is authorized to give possession of
(Creme ay Name)
the remains to Mason Funeral Home by delivery
(Funeral Home Nana)
in person or by registered mail.
Eleanor R. Clark
(Name of Deceased)
DOS-1898-f(Rev.08/15) Page 2 of 3
Authorization for Cremation and Disposition
(Initial the following)
I/We understand that if the remains are not
claimed within 120 days of cremation,
�I gfaf4 may dispose of the remains in
(Name o/Cremelory)
an irretrievable manner,such as by scattering.
CREMATION CONTAINER/URN
(Initial ONE of the following)
0—La—
An urn to be used as a container for the cremated remains has been purchased from Mason Funeral Home
and is described as follows: Eagle Urns— Cultured Granite with Lighthouse
I/We understand that if the urn is too small to hold the entire cremated remains,an additional rigid container may be used for delivery.
-OR-
An urn is not yet purchased. INVe understand that if no urn is purchased or otherwise provided
�II)�J✓F� will place the cremated remains in
(Name ofCrametW)
a rigid temporary container for delivery.
This Authorization Form was provided by Bruce K. Mason was executed at
(Funeral Director Name)
Mason Funeral Home
(Funeral Home Name)
18 George St. , Fort Ann, NY, 12827
(Funeral Home Address)
and is signed by the funeral director as witness to its execution.
I/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 Form,attest(s)
to the accuracy and completeness of the information contained in this Authorization Form and authorize(s)the foregoing.
Signed this day of A04 Y .20 /91 .
Q
/ 6rL or�Printed Name �njrlature
33 School St. , Whitehall, NY, 12887
Address
Typed or Printed Name Signature
Address
Typed or Printed Name Signature
Address
WITNESS:
Bruce K. Mason � / ,
(F nerel Director Tynad r Printed Nam41 (Flrnaral Director Slonaf ire)
(Registration
61
Eleanor R. Clark
(Name of Deceased)
DOS-1898-f(Rev. 08/15) Page 3 of 3
Pine View Cemetery and Crelnatorrunl
21 Quaker Road
Queensbury, NY 12804
Authorization to Separate Cremated Remains
Funeral Houk m }------------ r ----= ----------------------------------
Directol-----------------ROCE -K---t-qs°�--------- -----------------------
Dale 5 Z IIt-------------------rah No.----------300
--------------- ------------
I/wc authorize the separation of the creiiiatc(l rc111allis OI
-------------------- E[Ego(�--- ���K--------------------------------
I/we Illrtllcr agrcc to hold hal-1111CSs, llldeninily and (Iclend the llci In 1lanlcd crClllilt0l'111►11 i1S WCII
its their representatives, Irons and agminst all clitlins, liabilities or daiiiages whatsoever which may
res111t front 1111S autllol-iratioll.
Si,natulc L 5;
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Crematory Operatorr -------__ __--
March 2015