Hedden Jr. Kenneth A. floc Vices Ccmcwvy & C;re11)M.c)1-iulll
Quaku Road
Quu,imbury, NY 1 280/4,
(> 18) 741,5-4477 ter 01 8) 746-44-76
Gise No.
Maim Ahj-p-g�
Izeclueste:cl Rtturn 'I'icne_.._ . d
Date of Cre nalionI1L11ft--;r1mc St,u tt:el_ `l_jAtj..:I'inle C onll>{c fe(1...
Maud ill ):-Cold:
Placed ill Ref ve:ralion: ✓_.__.__—..___
Placed in Resort:
I ,e of conl�uner
Rem,ll'I;s
Place of Dcalll�% � �_�5�} _._......_�_O�1.IS►_.^ .._-61ew v �-I ! '
I
st1mai-ed W(1�'Ill.of Remains ail<l LOlilalnel'_____ �._ _..__.__.._. 2L. _.� __________
Dale&Time Rcncai.cis arrivcd at.Creulat.os'y_.__l.v�� -
—___ _.._..___......._.___.___._.__.__
Nalilc of rumwal Director or 12cgisterc(1 Resident. Dclivu-irlf;
Detwied reason fOr ((clay if vemais)s were tw'CI lllcd Vlore plan !IH Isom," t/roll( time OI acccl)tcd
delivery
Retort Numbu in which Remains were crcmmc(l _
Notc:`1 he Crc;nlittioll C,o-; shall I)c rctaille d ill dic t ulmlllelli. file of 111C Crumilory
New York State
Department of State
NEW YORK 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 Authorhadon Form must be completed and signed prior to delivery of remains for cremation.
Number.
Crematory Name:Pine View Crematory
Address: -I Qvkl(,u POAD agLj..sWdW PA1, 11f0 Phone: (SI;Z )W-NMll
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is carried out by placing the remains of the deceased and the container holding the retrains into a cremation chamber where
they are subjected to intense heat and flame. The heat and flame will Incinerate and consune 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 m)nima)dust and residue wrll likely be left behind. The crematory will separate incidental and feign 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 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& 'FMEp�J / / �� * I i� Marital Status: M per'!-%p�
Name of Deceased: 7CtiA��/`1 �`7 C�CI N y l
Last Known Address: 1'9 S-,�1 kA A)C-2/- KC+. �C/,/mil eV h AK e. � _f �
Place of Death: ClP�,`.S I—A��S !Y�5/�i/�J f' ( n_ ���t:� �p/� i?S�c
Sex: 15(M ❑F Age:,JCDOB: &2LI I Date of Death: 01110 Y c Estimated Weight: 0
Description of casketicontainer in which remains will be delivered. _
�Flor'eN c-& @as+- 7-6 . nr A,�-- 1.;v 4 e -" 7o v Z,6 a 1 IA;of e
PERSON IN CONTROL OF DISPOSITION
(Person(s)in control of disposition,initial ONE of the following)
f amNVe are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
Health Law Section 4201.
-0p'-
� * I/We 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 remains and Uwe 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:
E?NCI Chi Jde it l r J;
RUMOrDWWWO
DOS-18984(Rev.08/15) Page 1 of 3
Authorization for Cremation and Disposition
(Insert iran me ristbebN
Number- Description
1. A person designated in writing pursuant to Public Health Law Section 42DI(3);
2. The surviving spouse;
2a. The surviving domestic partner,
3. Any surviving child eighteen years of age or olden;
4. A surviving parent;
5. A surviving sibling eighteen years of age or older;
B. A lawfully a"rned guardian;
7. Any person(s)eighteen years of age or older entitled to share in the estate and who islare closest in relationship to the deceased;
* A duly appointed fiduciary of the estate;
9. A dose friend or relative who has executed a written statement pursuant io Public Health Law Section 4201(7);
10. A drW fiscal offioer of a ema ty or a public administrator appointed pcesuam to ttte 9urrogaWs Coat 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).
(M ' ALL THREE of the following)
Me hereby affirm that the body of the deceased not contain a batt battery pads,power cell,radioactive implant,
or radioactive device and alai any such materials were removed prior to the wac utlon of this Authortifon Form. Failure to remove
these items prior to cremation may result In harm to the crematory and/crematory personnel.
0 Gf Al �
iMle affirm that instructions have been given to J---rqmW f�.
regarding the removal of any personal property or other third of value whim any person signing below or any family member of the
deceased wishes to preserve. Pine View Crematory
rCMWon NWW
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.
iMle hereby authorize Pine View Crematory
(a
to cremate the resins of the dam.
FINAL VIOPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is.
Name.Any Staff from the I&ward L Kelly Funeral Home
Address:1019 US Rt 9 PO Box 548,Sctuoon Lake,Ny 12870 Phone:518.632 7177
The cremated remains of deceased will be disposed-of as follows:
PA)
if for any reason the person named above does not take possession of the cremated remains,
Pine View Crematory is authorized to give possession of
(CMM+rw AbnW
the remains to Ford L Kelly Funeral Home
by delivery
in person or by registered mail.
jY
(Ah—d
D03-189&f(Rev.08115) Page 2 of 3
Authorization for Cremation and Disposition
lnitr 1 the following)
[Me understand that if the remains are not claimed within 120 days of cremation,
P(ne View Crematory may dispose of the remains in
ftnre O Cremabry)
an irretrievable manner,such as by scattering.
CREMATION CONTAINERIURN
(l rdal ONE of the following)
An um to be used as a container for the led re�mQ�ains has been purchased from Edward L Kelly Funeral Home
and is described as follows: f
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.
-OR
is of y pu ased. 1Mic;
71.
at if rao !s porch or sew vi ed
J L---h� T / will place the cremated remains in
(N Q6ote0D/yJ
a rigid temporary container for delivery_
This Authorhadon Form was provided by 0 i ! / was executed at
(Ftm&el DdrectarAWM)
Edward L Kelly Funeral Home
1019 US Rt.9,PO Box 548 Schroon Lake,NY 12870 � )
(Funeral Nana Address)
and is signed by the funeral director as witness to its execution.
Me have received a completed copy of this AuthoriaWon Form.
The person(s)identified below islare 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 Y v�U e�'1�'�~ .20
fj L A . He
Typed orPAeled Name Sipnsture
�l r0� A A-!
Typed arPriMedN&w
Ad"ss
Typed orpm1w Name gee
AdMM
WITNESS ]
AmeralaveCLarTypedor Narnoj tF Sgnafuml
l/ O
((egstraff-NemW
(NmearDecmwo
DOS-1898-f(Rev.08/15) Page 3 of 3