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New York State
idEW YORK Department of State
Division of DIVISION OF CEMETERIES
STATE OF One Commerce Plaza
aPPORTUNtTY_ Cemeteries 99 Washington Avenue
Albany.NY=1-0001
Telephone:(518)474.6226
www.dos.ny.gov
Authorization for Cremation and Disposition
This Authorization Form must be completed and signed prior to delivery of remains for Cremation.
Date: 17 t i l I 1 S Number. g Z L
Crematory Name:Pine Yew Crematory
Address: 6414U NNO n (ZJyL� Phone: !O YJ--
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 wiii take reasonable efforts to remove all of the remains and other material from the cremation
chamber,but some minimal dust and residue wil)likely be Jett behind. The crematory MY 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:Fr- r e—i -s 0&) Marital Status. ✓ 'q ri e
Last Known Address: � � A) y s
Place of Death:� �6�I'Zi)rw:� f'�mm�ar,'r v /�Ir I At 43 FSes Lgiw!) Laic)10
Sex: 1%M ❑F Age-.__& DOB: f� add //�S�U Date of Death: / / I `/ Estimated Weight: ' g
Description of casketicontainer in which remains will be delivered. - i S
ft6k-eW,.� i^z+yl A� �U k: (A!!��r �f/U� 4i;,y aO
PERSON IN CONTROL OF DISPOSITION
(Pers n(s)in control of disposition,initial ONE of the following)
1 am/We are the designated agent of the deceased designated in a will or written instrument exearted 9 a9 19 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 tier 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:
(Name arDSCM-0
DOS-1898#(Rev.08115) Page 1 of 3
Authorization for Cremation and Disposition
pnaert from the W below)
Number. --S _. Description: IS r /`C.►�
1. A person designated in writing pumsuant to Public Health Law Section 4201(3);
2 The surviving spouse;
22. The surviving domestic partner.
3. Any surviving child eighteen years of age or older;
4. A surviving panes
& 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 islare closest in relationship to the deceased;
8. A duly appointed fiduciary of the estate;
9. A dose 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 admkdsMdDr appointed pursuant to the SUMV011 e'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).
(!a[ALL THREE ofihe following)
Me 11091 y affirm that the fly of the deceased d not contain a ,be"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.
� G UWe affirm that Instructions have been givers to
o�orve�y
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
(Clemby 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 wiU be destroyed by the cremation prod and cannot be retrieved after cremation.
UWe hereby authorize Pine brew Crematory
to cremate the remains of Use 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 RL 9 PO Box 548,Scimon Lake,Ny 12870 Phone:518-M-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
rcreaara�rvraew�
the remains to Edward L Kelly Funeral Home by delivery
[�na►f+omexa�
in person or by registered mail.
�r�`� C re- c,►�
dOeossatcQ
D03-1898-f(Rev.08115) Page 2 of 3
Authorization for Cremation and Disposition
(ini'vet tl;e fallowing)
GI/We understand that if the remains are not claimed within 120 days of cremation,
Pine View Crematory may dispose of the remains in
(Name o/flrmnebry)
an irretrievable manner,such as by scattering.
CREMATION CONTAINERIURN
(g al ONE of the fallowing)
_ An urn to be used as a container for the cremated remains has been purchased from Edward L Kelly Funeral Home
and is described as hollows: 9',' L--
INVe understand that if the um is too small to hold the entire cremated remains,an additional rigid container may be used for delivery.
-OR-
5 nn yet urchas a understand that if no urn is purchased or otherwise provided
V
" will place the cremated remains in
(M 0ofCremataW
a rigid temporary container for delivery_
This Authorization Form was provided by �'"' "��' '\�! was executed at
(Frmerai Dire�ror nlame)
Edward L Kelly Funeral Home
1019 US Rt.9,PO Box 548 Schroon Lake,NY 12870 Fwr, a Ho—Acme)
(Funeral hb—Address)
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 is/are the person(s)In control of disposition,who by signing this Authorization Fonn,atbesgs)
to the accuracy and completeness of the information contained in this Aufhorimfion Form and authorize(s)the foregoing.
Signed this day of 0 2 c--e •1 `1` ,20Cry
1
T,pap� Nam
7 �7 Clilq rt rdr'1
AMM _.
Typed orPrMW Naar
Address
TYpW or Printed Name
AMaress
WITNESS:
(Fuaerata"iciarTiMd P,intadit—) (F )
ok)
1 af` )
DOS-1898-f(Rev.08/15) Page 3 of 3