Basard Rose Marie Qu;lka [fowl
Que(;,Mbury, NY 128011,
745-1I,1I-77 or (.i 18) 74.1-/147(>
I'micl-al IJoiirc;
Itecluesl.ed ROL11-11 'l`ir,1e N0P
No. gZ
Date of G•e;nialion �Zff 13�IS 't'inic Stu ..
OMPIccul
i'lacecl in I-1 1 -
Placed in Itefrigeraholl:
Placed in Rel'.ort:
--•--__..__!fin.._._
-l•ylre of Corif.uncr 1 (A�, 1I.
Remarks
Main MOv
Z � �
P1,lcc 01'Dcalh
U,slilm cd We i�;hl. of ltcri�;iins :uul C'onl;�incr_ —
Date&Time 11c11i:iins arrived al.Crcrrr,rtorY_.. �2 tL I
l 5 r. vo
Name al funeral Direel.ov or Itc"Isty-cd Rcsicicnt. nclivei i�rl;' fZCn,;ui,s
Dewed reason for clekly il'rcnuuns were crenml.cd 11101-c than 4.8 hours I'rom lime ofacccpc
delivery
Retort Nunrl>cr in which Rer►rtins were crciii;it.ccl
Nole:'I'Ire Cren�atiol� (,oh sh;rll lac rcl;tinccl in 111c P llImICIll. I ilc 01*tltc CIcnt;ttory
NYS Department of State
!-authorization for Cremation and Disposition Division of Cemeteries
One commence Plaza,99 Washington Avenue
Albany,W 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: Number:
Crematory Name: u
Address
s g� 2 /-2& Phone�0 —AE 7�
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 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 DECEA5FD-
21
j �p Marital Status: PJ/A d uQ r�
Name of Deceased: .0 At,,C `f
J�f�119.1� �'Il,� ' �, 11�L��tiL✓L: M��oZyUY
Last Known Address: Z, S �l fl
f
Place of Death: Tj� Pu�sUV�
Sex: ❑M VF Age:
DOB: •��7 ,r, Date of Death:j. ,2 Estimated Weight:
Description of casket/container in which remains will be delivered:
11�At
PERSON IN CONTROL OF DISPOSITION
Zrson(s)in control of disposition, in�' 1 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-
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 r mains and (continued next page)
lA�D
Page 1 of 3
DOS-189844 (Rev.01/10)
Name of Deceased
t 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 below)
Number:_ Description: .)Ag
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;
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).
(Ja ial 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. ��
I a
/We hereby affirm that instructions have been given to(funeral director name)
mily
&dingthe removal of any personal property or other thing lue which any person signing below or any is not
member of the deceased wishes to preserve. (crematory name) C
responsible for removal of personal items from the container or from the remains of the deceased. Personal items
process and cannot be retrieved
left in the container or with the remains will be destroyed by the cremation
after cremation.
/�
/u to cremate the
UWe hereby authorize(crematory name)21-1jLU! CL V-a
r ins of the deceased.
FINAL DISPOSITION
The person authorized to We the cremated remains of the deceased from the crematory is:
Name:
Address: Phone: �� 25U `�
The cremated remains of deceased will be disposed of as follows:
�77.1-A-A1`g--Q T �`l��
If for any reason-the person named above oes not take possession of the cremated remains,
(crematory name) �xl V !k1�' �/ is authorized to give possession of the remains to
,�/,/ �_ by delivery in person or by registered mail.
(funeral home name)
Name of Deceased Page 2 of 3
DOS-1898-N (Rev.01/10)
Q&)j.tke following)
W I/We uwlprstand that if the re ains are not claimed within 120 days of cremation,
(Crum story name) "I£L✓ G f�l�7Z�/�� may dispose of the remains in an irretrievable manner,
such as by scattering. -
CREMATION CONTAINERIURN
(India)ONE of the following)
An um to be used as a container for the cremated remains has been purchased from
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 um as not yet been purchased. I/We understand that if no urn is purchased or otherwise provided
(crematory name) will place the cremated remains in a rigid temporary
container for delivery.
This Authorization Form was provi by (funeral direcW name)
was executed at(funeral home name) �u•c�e Q Pr .0
(funeral home address)�1 c J �ici2� �S f—iy ��_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 anyd�authorize(s)the foregoing.
Signed this day of 69r(-,&LY,6-'AQ 20
MR
Typed or Printed Name Sig re
Address
Typed or Printed Name Signature
Address
Typed or Printed Name Signature
Address
WITNE S:
Funeral Director Typed or Printed Name Funeral Director Signature
ZIQ 9�i
Registration Number
J`tlJ
DOS-189844 (Rev.01110) Name of Deceased Page 3 of 3