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Dck)rt Number iov,hid, Dun1n1nx *zrccrcmxicd �m�^ -'-----------------
WS D"artment of State
Authorization for Cremation and Disposition D of dieted"
one cotttmett:e Plaza.99 vvndngton Avenue
Albany,NY 12231
(518)474-8226
www.dos.state.ny.us
This Authorizedon Four►must be completed and signed prior to delivery of remains for cremation.
Date; Q Number.
Crematory Name:
Address: (xiUA- �Z Phone:., 70 <-ly7
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 crematlon.
able efforts to remove all of the remains and other material from
Following cremation,the crematory will take reason
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.
OPENING OF CONTAINER
The crematory may only open the container holding the un-cremated human remains in limited circumstances
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
Name of Deceased: e aQ Marital Status: V/
Last Known Address: L
Place of Death: mod'
Sex: WM OF Age:S11 DOB: Date of Death: Estimated Weight:
Description of casket/container in which remains will be delivered:
Nei
PERSON IN CONTROL OF DISPOSITION
(Person(s)in control of disposition,kM 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.
-O
IMe 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 remains and (Continued next page
Page 1 of 3
DOS-1898 4 (Rev.01f10)
Name of Deceased
I am/we qre 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. Description: !��
1 'O
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,
S.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;
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 Surrogates 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).
(kffld4U THREE of the following)
i/We hereby affirm that the body of the deceased does not contain a battery, battery pack, power cell,
ra inactive implant,or radioactive device and that any such materials were removed prior to the execution of this
Authorization Fom�. Failure tD remove these items prior tD crerr>tation may result in harm t4 bory and
crematory personnet. _
I/We hereby affirm that instructions have been given to(funeral dmdarname) r�
riling the removal of any personal property or other thing lue whi any person signing below or any family
member of the deceased wishes to preserve. («emavyneme) 1Lr ��7''�.�-n'" ,/ is not
responsible for removal of personal items from the container or from the remains of the deceased. Personal iteems
left in the container or with the remains will be destroyed by the cremation process and cannot be retrieved
aftl cremation. n
UWe hereby authorize Gory name) (A-) ` i F 07 4!` t it l to cremate the
ibM11—n9 of the deceased.
FINAL DISPOSITION ••
The personaZek—
zed to receiv cremated remains of the deceased from the crematory is:
Name:
/ Z Phone <
d
Address: / �"�
The cremated remains of deceased will be disposed of as follows:
L�11-4 '/
If for any reason the person named 9pove does not take possession of the cremated remains,
( ) wif v y� y.� is authorized to give possession of the remains to
by delivery in person or by registered mail.
(funeral home name)
6AJ
Pape 2 of 3
DOS-189844 (Rev.01110)
� s
( Mowing)
'alNVe�d that if the mains are not claimed within 120 days of cremation,
( go y name) 20W!£4) may dispose of the remains in an irretrievable manner,
such as by scattering.
CREMATION CONTAINERAJRN
((p/tial 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:
I/We understand that if the um is too small to hold the entire cremated remains,an additional rigid container may be
used for delivery.
An n purchased. WVe understand that if no um is purchased or otherwise provided
atwyname) �'��cEtJ C �D`i�1-r'��c C�/�l�will place the cremated remains in a rigid temporary
container for delivery.
This Authorization Form was provid by(funeraldirwwneme)
r
was executed at(funerat home name)
(funeral Home address) CO and Is signed by the funeral director
as witness to its execution.
Me have received a completed copy of this Authorization Form.
The persons)Identified below Ware the persons)in control of disposition,who by signing this
Authorization Form,attsst(s)to the accuracy and completeness of the information contained in this
Authorization Form and authorize(*)the foregoing.
Si red this ,—day of�� 20�.
nn i e-- /ye -c On
Typed or
Address
Typed or Printed Nww Siynaturo
Address
Typed or Printed Name SOUMm
Address
WITNESS•
F
Funeral rector or Prin Name i
DOS-189t I4 (Rev.MAO) Name of Deceesed Page 3 of 3 j