Faughnan, Richard C. '
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W YMK IV�S�Ot1 Lff Daw"Mm cftlaat,
/+� OMSM OF CEMET�
OPPARMITY Cemeteries L� �r�� Orn Commerce plow
Ud66hinpioe Avpnua
areas.,NY 11$8 4M
Teleprrone:(51Mara.622e'
Authorizaltlon!or C►o.mation and Mapar>mon wWW.ft1.rr/4w
This Autfior&vffm Rornh must 6e camplsud And signed prior to delivlry of remains for tranatfon.
Number. V
Cremat4ryN �t�. l�I�Q �� YY1a vrg
Address: rCil
F'how, � �1_►# Lo
CREMATION IS AN IRREVERWOU AND FINAL PROCEW.
Cremetlon 18 Carded out by placing Ihp rermhu.of the dowased and the 0011A finer holding th6 ft±rr>dina bo
8L*C
019Y etrd m
ta><D a cnemAtior►chamber wltdre
are led to inWft heat and Aarhe, The heat and fiarne Willi IncMwrate Artd consume ewii►�id9 except na erol,
nhkit are all that wiq be Nft aftw er onftn,
Following cremation,the oremat xy wlA take r�enaww la afkut5 to rtmorp ail of ft reltleine anti other malarial frofn the Qerr+atlon
chamber,f>ut Some►nlnhnAl Rust and residue will filers be left behind. The crematory will Aeparab kwWo W ana0 for tgn n"Wal tt�m
the remains and I tb UhCiWnWl and Wftn maletlal YA be dlepose d of as required by law, The d MMW mmaina will be megiemrc elly
Pulvb lmd k*enroll Plem and pieced Into a ciatdpnafed="bloc Of um. Cry mabad remalm gemmk AM p.ukwlsed owl no
'i"Qla,fte is MwYnLoWe as•kelowlyissue.
The crorf way may o*qq3er the Container holding the un-erent5W human rep a in IknaW cWCLNft u=,such p confirm tnt
Kt@nt71y of the deceased or to ensure ttrgt no material Is eneiaseid which miaM injure employees or damEige the such s t property. N
tn,man nntpllls NO dNhrwW in a eontobw wIdCh is not-21AI ebls fo►arematlon own as Ceremonial or ren I eadoM,on
w""bory wM requhy that the r alnc be moved into a wilable coetalnar 110116m It scwpb the rsmairm The aPe+►►V at a
��aryo��nla��in��eyr'M N18 tMnsfOr or fernw A)Of rEmAUts wllr be OW41,iCled beftu q WIft t9 and will be dw*in p Micy.*"d03*y and MWQCL
�+1a1ar�Y_r�gri�L+
Name of Dfteased: Npribrl 3tatraa:Ck unael4
Last Known Addrm,
Place of Death: (22vb� atnn
Sex: JA F' Age: Dog. a —�Q�>Lp gate of DWM; a_ f aDoacriM
n of ceWWbontalnar in which remains will be delivered.
Of diapealbrort 01VE of ft coal AVM
Hea t1 LbtAr Section4201, designated agent of the dec aned desigrwind In a W or*ditn in ftrrient e7re"d pursuant to Publcc,
-OR-
UM how no knowledge that the deceaW emadded a wrimen(matrumern Pursuant tD Public Me8h Law will 00Wfilning difw*w s 1br the dispesltion Of f�or her remalns and Uwe ere Lew Aer90 s ha wort Lek or a
SaCtion�4201 and have the rtght to fruthorbm crAnrfation of the remains of the daftasad*#Ourrrrr NO Ibr Pttbifc Flea a taw
foflowo; Mp to the deceased Is an
008-1895-f(Rev.OW15) Page 9 of 3.
12/12/2019 5:23PM (GMT-05:00)
Authorization for Crenmation and Disposition
ansattfmm the harbelov►q
Number:#1 4#3pesctlption
1. A person dr slgrwted in 2. The 8urvivinp spouse; wiftfng pursuant HOW Public He Low Section 4201(3);
29. The aurviving domeSk partner,
3• Any aurvrving&NM eighteen years of age or ofdtr,
4. A surviving parent
e• A s sibling eighteen ysgm Of age or eider,
B A Iawhrrly aMointed guardian;
7. Any Person(s)elllhtsan years of Ve of older entitled to shere in the 4mtate and who igditre alftmt in rtrtionshfp to the deceased;
& A duly sqpoklted fiduciary of the estate;
9- A e►rfef ��o�e who
o has ex oft a wrM en Otatenun t pursuant to PUbk Health
10. A �' public sdminfstrator eplsoinW punwant to the$ Law Section 4201(7);
°tw PeMn who is Ong on behaff of the deceased and who has executed a u�9e"Court P+»asdure Act.,
LOW Section 4201(7). wrMYn stdff!r Rt Pursuranf to Public Health
ITChof Me wow/AD)
emby affrtm that the body of itrG aeoeased does not cofatain a belEery,bat*y PR*.Power t�gll,rsdlogctive 6++plant,
or radlogc4ve delsoc and that any such rtMteriaLg were remaued prior to the PR*.
of this A&MM&at/on I"atm, Falhun to remeva
these items prior to o wRtIon"my result In harm to the crpelatery and cmtlat"poMannel.
afllrm that I►rmtructl6na hevp been given to •i
. crnua,
rtiing ttre removal Of any personal Prgm ty or other thlno of value which any Person signing below or any famify"comber of fhe
det:e&sed wtohes to preserve,
i,not raapv► a for the removai of pefbondt sterna firom the aohtdiner or from the mrmeins or the deceased. Pm enact ftlem le*in the
OMco►rbinaro with f1W remalrrs wfN be ematr,pyed ErY pw cremation process and Cannot be refrlared affier nrai ilea '
�mre r�w.by aut►orio , il..)i p L>-�
to crenate the rntllirte of oke,ooceaaw.
The Parlor authorized to rawim the cremated n mft of the deceased from the crematory Se:
Name:
Address: s
h' ► Phone: e1" I 114
The ct+eMated remaihs of deceased will be disposed of as falfts: I
If for any reason t)te person named above deem
not fake pt>aseasfart of Ure uern2led n91tt8i►!s,
n fOmvltsur�, is auWWd to glvs possession of
the remains to it (,k.f"1 ,+1�1
t>ti+rwtMornervrnNj •—•�•.—.—,° ,�by delivery
in person or by rogisteMd Mgli,
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Do&isaa-f(Rey,08/15) r� r0°Or
Pegs 2 of 3
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Authorlt ffon for Cremation and Dlapoaftion
understafd that if the remain SIPO nOt 611131med Wkhln 12D days of cremation,
`may dlspcae of the►sm*Wm in
an irretrievable manner,Such as by 904t6er , ixaM
C
(llr ONC of the foRowinyj
An um to be used as a i1w kw the cremated rgmafny ft s been pure ftm
and Is d000 lord w idk>wa
JN*undeffi%nd tfiet If the um is too srnaff to hold the entire cremated rams[%an aM*nvl N910 Container may to Lmad for deftsry,
h um is net yet Pumhaeed, WVe understand that It no um is Pui'Cf'used or etherwiee providod
yet I-I
nfAR place tfta.&ww#Md eemakm in
a rigid tmnpoMry Container for deli►".
ThW Au NatUaelbo Fans was proAded by ~l Q was P,QecuEod at
rrwiorerrawaa�rnrt
El
n
I'1�neralhfenneAbnq)
End is signed by tt►9 funeral Qfip=as w bmu fo jiff ftearHen,
Ui11da have mWvad 9 cQMPWW copy of this Au* dkw& lion Form,
The iwtsoe(s)idaMftd bek w tales Q*fiprew(m)in control at ctWpos#Wm.who by aVMnO tff<a AWharmmkw FpiesnesouskIN dn cofthod In this A�Fom and suUmss)Ih+ og olrgbR ie aeonoyrndeam � e1f,alo.
fa)
Spadthio_ dayof I o
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or
K ha
ot8ry ublic,State Ot NeW York
Qualified in Albany County
d �
Commission Expires March 03,ZO.�
,aaao
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tr�urerrr�eeorvoriYeArem� d.ra.ca.sywrw.t .
WHIM wmrt dry
DMIBQ&f(Rev.O IS) Peso 3 of 3
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