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Wells, Francis M. 76 I71I1C View CC.MC(l(;%-Y Ll� (;1'CtT12ll.C)1'IUITI Quilka Road QUOU115 >ul-Y, NY 1280/4, 18) 745-4477 or (.i 1 H) 74 ;-447G Fklllcr,ll l-lolttc [Yl..r...''• ____ lte<tuesce cl 1Zc Lunt Time A1v k Name ;. �_._ � / �� C,ase No. Date of- Crclnal;on_/ __ l'inlC 81al d 7 .'I'irltc Coillt>Im-d �------ Placed in Hold: _L `-- Placed in Rcli•ige;rahotl: Z Zo 41119 Placed in Rawl: _-- Type of Cont,uncr •..j I I __.�o_�. _....�. ._ ._j Rent:u•ks Mails Movc D ---------------- rd�,? 1 _ lace of Deat11 [;atint,tt.ed weight. of Remains and Colttaincr____O� - Date ZZ'1'intc Rctnains arrived al.C;rcnt,tlor ��- __��=��--� • Name of FLUILr,l1 Director or Rccisccrcd Rc;sidcnt. Dclivering DeUtilcd reason for cic ay if remains we re ercnutLccl ntorc (Iran 1I$ !tours front tithe of ;lcccl>Ced - delivery Retort Nulilbcr in which Rclttains were crcnt:Itccl Notc:The Crcul,clioll C,oh shall l>c ret:tinecl in rite l'crtn,utelli. 1'11c: Of tltc Crenl:uory -'-- 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:,)$ 6q Number: Crematory Name:Pine View Crematory Address:Quaker Road, Queensbury, NY 12804 Phone:518-745-4477 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 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 OF DECEASED JJ Name of Deceased: R�an e-3 M Marital Status: Q Last Known Address: 31 '1 Z02— Place of Death: �r ldbt2n Ali li' hQ rye or"t ��Lc l�i'�/ /ZW Sex: ®M F Age: go DOB: '3—(R- IgZ-q Date of Death: Estimated Weight: Description of casket/container in which remains will be delivered: cremation container Ma C�na / �'" 4� i C / n f>c "u S, WOA 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- X & 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 (Continued next page) bra ri ces l�e(�s DOS-18984-1 (Rev.01/10) Name of Deceased Page 1 of 3 I am/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 list below) Number: 3 Description: 1.A person designated in writing pursuant to Pub c 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§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§4201(7). (Initial ALL THREE of the following) 1/We hereby affirm that the body of the deceased does not contain a battery, battery pack, power cell, ra active 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. I/We hereby affirm that instructions have been given to (funeraldirectornarno Michael Miller 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. (crematory name) Pine View Crematory is not responsible for 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 (crematofyname) Pine View Crematory 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:Miller Funeral Home Address:6357 State Rte. 30, Indian Lake, NY 12842 Phone:518-648-00 11 The cremated remains of deceased will be disposed of as follows: returned to funeral home staff If for any reason the person named above does not take possession of the cremated remains, (crematory name) Pine View Crematory is authorized to give possession of the remains to (funeral home name) Miller Funeral Home by delivery in person or by registered mail. +r-6-�c� I O l 0 U's DOS-1898-f-I (Rev.01/10) Name of Deceased Page 2 of 3 (Initial the following) I/We understand that if the remains are not claimed within 120 days of cremation, (crematory name) Pine View Crematory may dispose of the remains in an irretrievable manner, such as by scattering. CREMATION CONTAINER/URN (lni i I ONE of the following) An urn to be used as a container for the cremated remains has been purchased from ll,---r and is described as follows: w OC>Ql 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 has not yet been purchased. I/We understand that if no urn is purchased or otherwise provided (crematoryname) Pine View Crematory will place the cremated remains in a rigid temporary container for delivery. This Authorization Form was provided by (funeral directorname) Michael Miller was executed at(funeral home name)Miller Funeral Home (funeral home address) 6357 State Rte. 30, Indian Lake, NY 12842 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)NOY the foregoing. Signed this day of , 20—L�—. C--IA-1 Typed or P'nted Name Signature Address T0a00, Typed or Printed Name Signat /e L Address Typed or Printed Name Signature Address WITNESS: 11 Pa+T-I( Ca AdL/kc Funeral Director tt'iTyped or Printed Name Funeral Director Signature as— Registration Number fr wce GIN s DOS-1898-f-I (Rev.01/10) Name of Deceased Page 3 of 3