Metthe, Shirley Louise �
��iuo V(cw {\e»`ctu,y (k <�/zn,xkxium
()Ux�..Cr Road
`^ .08d
/\uutU,ikU[y. NY 12804
[5 711-5-11477 or (r)18) 74,5-4476
|( | K
Mm.0
Cxsc No.
Date of*Cn:ojx(lm`---I/ � /y; '[� �m _llmcc0n;>Ic(ud___----- ----'- '`�
y�rrJ_-~`. � -------���f
o}
Mxc«dill, Bz6*In 1x1,jo»:
Placed In Dobort,
`
lMmw[co»titiou.
�--------__-__--_------_---__�-------_.____-_----__--___----_-----_--_
------------------------' »«n«o �
------ ---------��--���-_1-_
Place of'Dca ),_ Dr
U,xhxmtedVVciX|)i of, Kooxiosxnd [\x\\xiuur________
D»L(!&ITincD�v`xiuux��v��\ xi(�rcouhory___
Nxmc [)irucior or
DokaibJ rcxyuo I,(),. de|xy ([vco�xi:� wcn: cocombd n�orc U ml �8 } {� � / �-------
dd�ory �'`' m«/� »»»� ho�c «(xcocix�J
. �
--------------
----------
Retort
�������������������������������������������_���
Nuo�>cr �n w/}�id, Dc i
No(c'i]^c CnxoxKi0U \vu Il|x\oui ill Uc Pcmww /i FiIc o[U/c c/zom(ory
NEW PORK Division of
STATE OF New York State
OPPORTUNITY_ Department of State
Cemeteries DIVISION OF CEMETERIES
One Commerce Plaza
99 Washington Avenue
Authorization for Cremation Albany'NY 12231-0001
oration and Disposition Telephonwww c)474g226
www.dos.ny,gov
This A�omation For
m must be completed and signed prior to delivery of remains for cremation.
Date: l2
Cremato ry Name:
Pine View Crematory Number. 7
Address. z r
+tit a�S•i;�.� L'r`'� f-Z
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS. Phone: S Tys'y
Cremation is carried out by placing the remains of the deceased and the container holdingth
they are subjected to intense heat and flame. The heat and flame will incinerate and consume
Which are all that will be left after cremation. e remains into a cremation chamber where
Following cremation,the crematory everything except bone and metal,
chamber,but some m)n)ma)dust and residue wi))Uke)y be)eft behind. The crematory tuiN separate other
ry will take reasonable efforts to remove all of the remains and other material from the cremation
the remains and the incidental and foreign material will be disposed of as required by law. The cremated re
pulverized into smell pieces and 1 g dental and foreign material from
placed into a designated container or um. Cremated remains generally are remains
eir until mechanically
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
identity of the deceased or to ensure that no material is enclosed which might injure employees or damage the such as to confirm the
crematory
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 If
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:
,�1
/h`�✓ n l!/ S2 r'/
� e-- Marital Status: �Q,`s de'o
Last Known Address: �{� /'�1 d;-f 1 Ai ,L;;"r'A e l �/� ti x,
/ Y-7L)
Place of Death:
Sex: ❑M &P;- Age: _ DOB: �.�f f 9 Date of Death: O X / Estimated Weight
Description of casket/container in which remains will be delivered.
+)c �a a -t-
( 'Y`Ai►'►�A l;� Crrh 1 f!/A.C'+' C1^�{'Al Cc� PA1 C 6e
PERSON IN CONTROL OF DISPOSMON
(Person(s)in control of disposition,in/tial ONE of the following)
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
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 1/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:
NJ (Nam aoe—seat
DOS-1898-f(Rev.08/15) Page 1 of 3
Authorization for Cremation and Disposition
(Insert from the list below) rl
Number.-3 Description:_S,<
1. A person designated in writing pursuant to Public Health Law Section 4201(3);
2. The surviving spouse:
22. The surviving domestic partner;
3. Any surviving chid eighteen years of age or older,
4. A surviving parent;
S. 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 Section 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 Section 4201(7).
(Initial ALL THREE of the following)
_I/We hereby affirm that the body of the decease( does not contain a batte battery pack,power cell,radioactive implant,
or radioactive device and that any such materials were remove 'or 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.
My 1 ►/We affirm that ins 7X \�— I instructions have been given to C n.
(Funeral Director Name)
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. Pine View Crematory
(Crematory Name)
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.
Me hereby authorize Pine View Crematory
(Crematory Name)
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:Any Staff from the Edward L. Kelly Funeral Home
Address: 1019 US Rt.9 PO Box 548, Schroon Lake,NY 12870 Phone: 518-532-7177
The cremated remains of deceased will be disposed of as follows:
, .
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
(Crematory Name)
the remains to Edward L Kelly Funeral Home by delivery
(Funeral Nome Name)
in person or by registered mail.
(Name or Deceased)
DOS-1898-f(Rev.08/15) Page 2 of 3
Authorization for Cremation and Disposition
(lnfd ! e following)
I/We understand that if the remains are not claimed within 120 days of cremation,
Pine View Crematory may dispose of the remains in
(Name of Crematory)
an irretrievable manner,such as by scattering.
CREMATION CONTAINERIURN
(Initial of the following)
An urn to be used as a container for the crematTIC
ains has been purchased from Edward L Kelly Funeral Home
and is described as follows: /�I AYfG�J Ge){'��
IIWe 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 ur is of purch ed. a undefstaLdth114 noasLd�o a 'se pro ' d
'N Jy 6V will place the cremated remains in
(Name of Crematory)
a rigid temporary container for delivery.
This Authorization Form was provided by was executed at
(Funml DtreCtor Name)
Edward L Kelly Funeral Home
1019 US Rt.9,PO Box 548 Schroon Lake, NY 12870 (Funeral Home Name)
(Funeral Home Address)
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 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 �v�/�ra�' ,20 y
Z' x AZ
Typed orPdrrted Name r �.�A- - -/
AMR=
Typed or Printed Name Signal—
Address
Typed or Printed Name Signature
AddreSS
WITNESS:
(Funeral Nred6r Typed or Pmod Name) (Funeral um}
u(M'
(�Number)
(Name ofDeceased)
DOS-1898-f(Rev.08115) Page 3 of 3