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Fish, Muriel V l'i►Ic �/ic�l' C;c:Il�ct.cry c� C:rc:lll,ltoriulll (�u�ll:cr Road (, uCc"sl)ury, IN Y l 280,1. (i 7,'1;5-,1.,1.77 car (,i 18) 746-1I.,1.76 I�Inlc;r,ll IIc>Illc 1 Ilc�<lucstccl (tclurll "I'illlc: /-^ 7 /9 l�'t Oatc of C;rcllrl�ic�►1 0o ------ -- No . --------- - 3 !'�I illlc ( oiiit�lc(ccl �l�yl>c o1�Colll,tillcl' _..�1,.�L�/f'tG1,>1�,� CII4U'ICs -"--^-- Kiil' _-- --.073by�- IVIOVC ----------------- Place of I'AillMiccl W6,111 cal Itclll;lins ,tllcl L'onl�iilu:r._/3� ��S ►lc &' Tjjjjctt�l ►15 �trri,c c) itt cll:Ill.ttUl, N;uuc ol• l�uncr;,l l�ircrt.c>r <>►' Itchistcrccl ltcsicicnl C)cli��crin,; Rclll;lills_��/fG ---�' / Deiailccl rc;lso,, I•or cickty 1l•1,(:1Mt'1cs wcrc c:rciu;klccl iiiorc tli;cn 6H Boll►ti II'cnll 11111C of ;U'c:clllccl ciclivcry __... ----------------------- -- lZclrnl Nunlllcr In which ftc►Irtins WC1*C c•rcflu►tccl Ncllc:"I'Ilc: LI'CI11;1(IOI1 l .<�;; sl�;ill I>c rct;�i��c<I M I11c I'ci ni;MCM I'ilc c Il,liclry• WS Deparnent of State Authorization for Cremation and Disposition Divisi on of One Commeroe plaza,99 YYasFangton Avenue Albany,W 12231 (518)474-6226 wwwAos.state.ny.us This Authorization Form must be completed and sign"prior to delivery of remains for cremation. Date: 3 Ql Number: 7 Crematory Name: l /tile ol uj Address: e o go ��F r LX ui2 /L / Phone: /S- �e/�' 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 um. Cremated remains generally are pulverized until no single fragment is recognizable as skeletal tissue. Mh =L" OF CONTAINERtory 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 yam/Name of Deceased: hS Marital Status: / l 1,C�2-�� n ©'C 2'�s-- ~'�`� loot).) Last KnewAddress: Z I Place of Death:_ (Q..��►�S �L� � � Sex: ❑M F Age: DOB: >7G} Date of Death: mil✓ Estimated Weight:' A— _ � Description of casket/container in which remains will be delivered: —ZJ6�4�Xl- PERS N�ONTB�r nc elSposIT10N (Person(s)in control of disposition, initial ONE of the following) executed I aml We are the designated agent of the deceased designated in a will or written instrument pursuant to Public Health Law section 4201. 4S . , have no knowledge that the deceased executed a written Instrument pursuant to Public Health law n 4201 or a will containing directions for the disposition of his or her a ins and (CmUnued ne�tpage) Name of Demsed Page 1 of 3 DOS-18Wf4 (Rev.01110) - I arrt/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: (Insert from the fist below) Number: 3 Description: S 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 duty appointed fiduciary of the estate; 8.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; half of the deceased and who has executed a written statement 10a.Any other person who is acting on be pursuant to Public Health Law§4201(7). fIM,AHREE of the following)e 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 Aut orization Form. Failure to remove these items prior to cremation May result in harm to the crematory and c a personnot. elA11 tc _ IIWe hereby affirm that instructions have been given to(funeraWhreawnna ) / signing below or any family regarding the removal of any personal property or other thing of lue Y Pe jt7�r�� is not member of the deceased wishes to preserve. (oiemamry name) /�`r`� e responsible for removal of personal items from the container or from the remains of the dace . Personal items left in the container or with the remains will be destroyed by the cremation process and cannot be retrieved a cre tion. j �'� ` IMIe hereby authorize(c+emer«rnerr,el Ul�� r R�'� to cremate the � remains of the deceased. FINAL DISPOSM The person auth ' ed to receive the cremated remains of the deceased from the crematory is: I Name: _ Address: ( 4+� J ►s� D) Phone: �� 7 The cremated remains of deceased will be disposed of as follows: L � If for any rea��.,,,ti,.nmmon named abo a does not take possession of the cremated remains, zy C'�4 ra .9-r'b iZ�_is authorized to give possession of the remains to ( a�Y name) by delivery in person or by registered mail. (funeral home name) �?��Cn1 r-!'— /.• Name of Deceased Page 2 0 DOS-189844 (Rev.01l10) L � ( following) 'fir I/We u�Ia�nlhal if thg r�maiin�reennot claimed within 120 days of cremation, (asmero y,nw C'��-ri may dispose of the remains in an irretrievable manner, such as by scattering. CREMATION CONTAINER/URN (Initial ONE of the following) An um to be used as a container for the cremated remains has been purchased from 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 u for livery. 224� An u snot yet been pu . Me understand that if no um is purchased or otherwise provided (aPmatory name) rzovt 0 k,.J —will place the cremated remains in a rigid temporary container for delivery. This Authorization Form was provid by Ouse dredor nwml was executed at(fur+erai home nano) ' ffuwW home ) and is signed by the funeral director as witness to its execution. Me have received a completed copy of this Authorization Form. The person(s)identified below istare the persons)in control of disposition,who by signing this Authorization Form,attests)to the accuracy and completeness of the information contained in this Authorization Form and authorize(s)the foregoing. Si ned this day of 20 / Typed or ted me C / Address Typed or Pdnted Name ftnetue Address Typed or Printed Name swotum Address WITNESS Fum&DAcw Typea a Printed Name Ragi Nu / �S/�z DOS-18WM (Rev.01M0) Nerve of t)eceaW Page 3 of 3