Cozzolino, Anna Pilic Vic.vv Ct ii�tl:r c y (.;rL�n2tLe)I iUIT1
Quaku. Road
Quk e(;)M jury, NY 1 Z80ia•
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Name of Rune rctl Dirccl.or or 11cgist.crcc) RC;SI(ICllt. Delivering
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Dec.06.2019 03:50 PM #1018 P 6/ 6
( the following) '
I/We,unders and,t t e r mitt a not clat ed ithin,120 days of cremation,
a (t a.. rl� W Y
(crematory name)IFt�ie 1lt�YJ ,;:rt? ory; ! may dispose of the remains in an irretrievable manner,
such as by scattering.
CREMATION_CQNTAINERNRN
Anto be used as a container for the cremated remains has been purchased from
-Miller Fuhura Aome 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.
-OR-
An urn has not yet been purchased. I/We understand that if no urn is purchased or otherwise provided
(crematory name) Pine View Crematory will place the cremated remains in a rigid temporary
container for delivery.
This Authorization Form was provided by(Arneral director name) Patricia,Miller
Was executed at(funeral home name)Miller Funeral Home
(funeral home address) 6357 State Rte. 30, Indian Lake, and is signed by the funeral director
as witness to its execution.
I/V1/e 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)the foregoing.
Signed this 5 day of December 20
Paul Cozzolino
Typed or Printed Name
38 Minkel Rd., Ossining, NY 10562
Address
Typed or Printed Name Signature
Address
Typed or Printed Name Signature
Address
WITNESS:
Patricia Miller
Funeral Director Typed or Printed Name Funeral Director S1g tp
12465
Registration Number
Anne Cozzolino
DOS-1888+1 (Rev.01110) Name of Decoasad Page 3 of 3
Dec.06.2019 03.49 PM #1018 P 9/ 6
I I �
NYS Department of State
Authorization for Cremation, and Disposition 11 Division of Cemetedes
i ; I one commerce Plaza,99 Washington Avenue
Albany,NY 12231
(518)474-6226
wwwAos.state.ny.us
This Authorization Form must be completed anal signed prior to delivery of remains for cremation.
Date: 12/5/2019 Number: gl b
i
Crematory Name:Pine View Crematory
Address:Quaker Road, Queensbury, NY 12804 I I Phone:518-7454477
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 ale subjected to intense heat and ilame,The heat and flame will incinerate and
consume everything except bone and metal;which are.all that gill be left after cremation.
Following cremation, the.cremetory will take reasonable efforts to,remove all of the remains and other material from
the cremation chamber, but some minimal dust and resi8ue 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 pulvet'iged 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 QF 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 icontainer 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.
IIZ� 'ICATION OF DECEASED
Name of Deceased: Anna Cozzolino i ; Marital Status: Never Married
Last Known Address: e204 NYS Rte. 30, Indian Lake, NY 12842
Place of Death: Long Lake DayHab, Long Lake, NY 12847
65 9/27/1954 12/3/2019 140
Sex: ®M ®F Age: DOB: Date of Death: Estimated Weight:
Description of casket/container in which remains will be delivered:
MacDonald Container Co. basic cardboard cremation container
PERSON IN CONTROL OF DJ$POSITION
(Person(s)in control of disposition, in' 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.
,....;• :,:<-�� I/VVe have no knowledg a' 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)
Anna Cozzollna
DOSS-1898 i-1 (Rev.01/10) Name of Deceased Page 1 of 3
Dec_06.2019 03:50 PM #1018 P 5/ 6'
i
I am/we are the person(s)having priority under Public Health Law Je,ctlon.4201 and have the right to authorize
cremation of the remains of the deceased. My/Our relationship tb'the deceased is as follows:
(Insert from the list below)
:Number: 5 Description: brother
1.A person designated in wrlbhg pursuant to Public Health Lawlsection 4201(3);
2.The surviving spouse;
2a.The surviving domestic partner; i
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 shar6 in the estate and who Ware closest in
relationship to the deceased;
B.A duly appointed fiduciary o> the,estate;
9.A close friend or relative who hats executed a written statement pursuant to Public Health Law§4201(7);
10.A chief fiscal officer of a cobnty 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).
0#jtluj ALL THREE of the following)
i;w 1 .a rh° IM/e hereby affirm that the body of the deceased does not:contain.a battery, battery�• • Y Y ry, pack, power cell,
radioactive implant, or radioactive device and that any such materialamere 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(fu"ra►directorname)
Patricia Miller
re arding 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.
UWe hereby authorize (cremetoyname) Pine View Crematory to cremate the
re a ns of the deceased.
FOAL 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:518-648-0011
The cremated remains of deceased will be disposed of as follows:
Return to family
If for any reason the person named above does not take possession of the cremated remains,
(cremarorynama) Pine View Crematory is authorized to give possession of the remains to
Miller Funeral Home
(rw�eia►nomename) by delivery in person or by registered mail.
Anna Cozzolino
008-1898-1-1 (Rev.01110) Name of Deceased Page 2 of 3