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New York State
Department of State
NEWYORK Division of DIVISION OF CEMETERIES
STATE OF One Commerce Plaza
OPPORTUNITY. Cemeteries 99 Washington Avenue
Albany,NY 12 2 31-00 01
Telephone:(518)474.6226
www.dos.nygov
Authorization for Cremation and Disposition
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date: 12/22/2019 Number.
Crematory Name: Plneview Crematorium
Address:21 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 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 DECEASED
Name of Deceased: Rodney May Marital Status
Last Known Address: 313 Palmer Avenue,Corinth, NY 12822
Place of Death: 313 Palmer Avenue, Corinth, NY 12822
❑ _>Sex: ®M 'F Age: DOB:-11 all 6.51a Date of Death: 12/2312019 Estimated Weight
Description of casket/container in which remains will be delivered.
(type/matedallmodeumanufacturer) Matthews Aurora Wood and Cardboard Cremation Container
PERSON IN CONTROL OF DISPOSITION
(Person(s)in control of disposition,kff2l 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 remains and I/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:
Rodney May
pwme of DecW384
DOS-1898-f(Rev.08115) Page 1 of 3
Authorization for Cremation and Disposition
(insert from the list below)
Number. 3 Description:Any surviving child eighteen years of age or older
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;
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;
S. A duly appointed fiduciary of the estate;
9. A close fiend 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).
&&4 ALL THREE of the following)
�> I/We 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 harm to the crematory and crematory personnel.
UWe affirm that instructions have been given to Robert 1. Densmore
(Fun"Director Nerve)
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.
Pineview Crematorium
(C-lay 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.
v `UWe hereby authorize Pineview Crematorium
(cremeray AW-)
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: Robert 1. Densmore
Address:7 Sherman Avenue,Corinth, NY 12822 Phone: (518)654-9285
The cremated remains of deceased will be disposed of as follows:
Committal at Saratoga National Cemetery
If for any reason the person named above does not take possession of the cremated remains,
Pineview Crematorium
is authorized to give possession of
(CrWnetory N—)
the remains to Densmore Funeral Home, Inc. by delivery
(Fur"Home Name)
in person or by registered mail.
Rodney May
(None ofDeceeseo
DOS-1898-f(Rev.08/15) Page 2 of 3
M
Authorization for Cremation and Disposition
Inim the following)
L� WVe understand that if the remains are not claimed within 120 days of cremation,
Pineview Crematorium may dispose of the remains in
@bms Of OWMbry)
an irretrievable manner, such as by scattering.
CREMATION CONTAINER/URN
(Initial ONE of the following)
,yk An urn to be used as a container for the cremated remains has been purchased from Densmore Funeral Home, Inc.
and is described as follows: 6A t r r
WVe understand that if the um is too small old the entire cremated remains,an additional rigid container may be used for delivery.
-OR-
An urn is not yet purchased. IIWe understand that if no um is purchased or otherwise provided
Pineview Crematorium
will place the cremated remains in
MameolCremefar)
a rigid temporary container for delivery.
This Authorization Form was provided by Robert 1. Densmore was executed at
(Fur"oNWWN—)
Densmore Funeral Home, Inc.
(Fanmal Moms name)
7 Sherman Avenue,Corinth,NY 12822
(FWWW Name Ad&-V
and is signed by the funeral director as witness to its execution.
INVe 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 23rd day of December 19
20
Dennis May
Typed orPdn W Name
112 Cross Mountain Trail,Georgetown,TX 78628
Address
Typed or Pdmed Name W—
Actft=
Typed or P~Nine Signature
Ad&W —
VATNESS:
Robert 1. Densmore
r"r WN DhecWor Typed or Rbftd Ns"W 9pneNre)
10910
Rodney May
(Name o/Deaws«Q
DOS-1898-f(Rev. 08/15) Page 3 of 3