Seidel, Margaret 1'111c Vic:w Ccmctary & C;rcina(.(�riutrt
(,quaker Road
Qumnibury, NY 12804,
(518) 745-4,477 or (1)18) 74-;)-4476
micral Home �o
lZeclucslecl Rclurn 'l'iute
Nautc-----------��," ± ---S�►�i.l_ - ....._.. (;ase No. g
Date ofCren)alionI0/2t11� 1'intcSt,utccl_ /o_rrAflTintcContl)Ictccl,.•„ l'
Placed in •told:
Placed in Refrigeratiotr:
Placed in Rctoru
Type of'ConWncr
Remarks
Main
------------------------- ----- -- - Movc_.._...... ---- ---....--.jL'1_0�
Place of Deatlt
Emintated WeigIa ol• item;Tins ;ut(1 COntRll)CI' 176
DaCc v'mine Rcinatns arrival al.Crcjj,;ttoq_ bill
Name of Funeral Director or 12cbistcrcd Rcsidenl. Delivering Rettta►ns nt-ff-- F"ID4
Dettiled reason Ior delay if re nrtins were crcnrtlecl delivery More than 48 hours Cron► timeof accepl.cd
Retort Number in which Rctt)ains were cretuatecl__
Notc:'l'ltc Cj-c,,t,uion Lod;shall l)c rctainecl in llic l'crntancnt. file oC tltc Crcma►ory
r NYS Department of State
Authorization for Cremation and Disposition Division of Cemeteries
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.
Date: 4D Number.
Crematory Name: /4)-Z JtttJ
Address �
a Phone:, Ikr y67
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.
OPENING 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 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 F ,
Name of Deceased: Marital Status: c) Cf-D
VAM
Last Known Address: 1� `�-*�
Place of Death: � � -LS � -
Sex: ❑M Age: DOB:
Date of Death: D Q Estimated Weight:Z
Description of casketteontainer in which remains will be delivered:
c
PERSON IN CONTROL AF DISPOSITION
(Person(s)in control of disposition,kg l 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-
UWe 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 re ins and (Continued next Page)
Alamo of Deceased Page 1 of 3
DOS-189844 (Rev.01110)
I 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:
(insert tiom the/lst below)
Number: 3 Description: •� (�1� � _
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,
G.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 SurrogaWs 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).
((IdW ALL THREE of the following)
UWe 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 arm to the tory and
crematory personnel. _
I/We hereby affirm that instructions have been given to(fimewdre lorneme) IQD�f�7'7"—
regarding the removal of any personal property or other thing of vejue which any perso signing below or any family
member of the deceased wishes to preserve. (awnstwy name) A7 is not
responsible for removal of personal items from the container or from the remains of the deceased. P&sonal items
left in the container or with the remains will Zle--ca'-4?
oyby the cremation process and cannot be retrieved
after cremation.
I/We hereby authorize(aematarynernels '�� to cremate the
remains of the deceased.
FINAL DI SPOStT10N
The persona orized to a the cremated remains of the deceased from the crematory is:
Name: ic�T
Address: v J4 Q ��� Phone
The cremated remains of deceased will be disposed of as follows:
If for any reason person named above does not take possession of the cremated remains,
(aemetorynameJ / Ul UJ �gri�tl is authorized to give possess
by delivery In person or by region ofrstered mac the s to
(furmal Wane rnmm) '
Pegs 2 of 3
oos-189844 (Rev.o1na)
Nerve of Aeoessed
v
(�QI (the following)
_ Me un d that if the remans are not claimed within 120 days of cremation,
(amatwYnaw,i /atlfU! r—may dispose of the remains in an irretrievable manner,
such as by scattering.
CREMATION CONTAINER/URN '
(10611 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:
VVVe understand that if the um is too small to hold the entire cremated remains,an additional rigid container may be
used for delivery.
-OR-
rT'" - An u as not yet been Qurchased. IlWe understand that if no urn is purchased or otherwise provided
frrvmaro y named 6 _o l-6k) G'-C z da will place the cremated remains in a rigid temporary
container for delivery.
This Authorization Form was pro ' b dbe w
was executed at(fmaw home 1
lane-►tome and is signed by the funeral director
as witness to its execution.
I/We have received a completed copy of this Authodw ion Form.
The person(s)identified below islare the person(s)in control of disposition,who by signing this
Authorization Form,attests)to the accuracy and cornplebmwas of the information contained in this
Authorization Form and apthorize(s)the foregoing.
Signed this IJ l day of 8 ef,0, 20
{_ts)lf C_V'-t'N
Typed or Pik ted Name
5- 89-' , 4-W
Address -
Typed or Printed Namegrtatufe
Address
Typed or Pruned AWM
Address
/1Y
� G �
F ohecMr r PWOr Name >:,u, aueaflr si use
Ftegistraffm Nu
Qr
of Pop 3 013
ppgt�gf-I (Rev.01M0) NNW