Loading...
O'Rourke, Stephen E. New York State Department of State NEW YORK Division of DIVISION OF CEMETERIES STATE OF One Commerce Plaza OPPORTUNITY. Cemeteries 99 Washington Avenue Albany,NY 12 2 31-0 0 01 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: 03/17/2020 Number: Crematory Name: Pine View Crematorium Address: 51 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 urn. 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: Stephen E. O'Rourke Marital Status: Divorced Last Known Address: 9 Queensbury Place, Queensbury, NY 12804 Place of Death: 9 Queensbury Place, Queensbury, NY 12804 Sex: ®M 13 F Age: .e-3 DOB: 4 Date of Death: 03/17/2020 Estimated Weight: Description of casket/container in which remains will be delivered. ff I PERSON IN CONTROL OF DISPOSITION (Person(s)in control of disposition, initial 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 ection 4201. -OR- I/We ave no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a will containing dir ctions for the disposition of his or her remains and I/we are the person(s)having priority under Public Health Law Section 4201 a have the right to authorize cremation of the remains of the deceased. My/Our relationship to the deceased is as follows: Stephen E. O'Rourke (Name o/Deceased) DOS-1898-f(Rev. 08/15) Page 1 of 3 Authorization for Cremation and Disposition (Insert from the list below) Number: 3 Description: Child 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 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). ((j1n'iqa1ALLEEofthefollowing) e hereby affirm that the body of the deceased does not contain a battery, battery pack, power cell, radioactive implant, or raevice and that any such materials were removed prior to the execution of this Authorization Form. Failure to remove t prior to cremation may result in harm to the crematory and crematory personnel. I e affirm that instructions have been given to Wendy M. Bulich (Funeral Dmd r Name) r e 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 Crematorium (Cremetay Na—) is not responsible for the removal of personal items from the container or from the remains of the deceased. Personal items left in the Fntainerwith the remains will be destroyed by the cremation process and cannot be retrieved after cremation. hereby authorize Pine View Crematorium (Cremetay 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: Regan Denny Stafford Funeral Home Address: 53 Quaker Rd. Queensbury, NY 12804 Phone: 518-792-1114 The cremated remains of deceased will be disposed of as follows: Returned to family If for any reason the person named above does not take possession of the cremated remains, Pine View Crematorium is authorized to give possession of (Cremetay Na—) the remains to Regan Denny Stafford Funeral Home by delivery (Funeral Hare Name) in person or by registered mail. Stephen E. O'Rourke (Name of Deceased) DOS-1898-f(Rev. 08/15) Page 2 of 3 Au 'zation for Cremation and Disposition (Initial the follow ) I/W understand that if the remains are not claimed within 120 days of cremation, Pine View Crematorium may dispose of the remains in (Name of Crematory) an irretrievable manner, such as by scattering. CREMATION CONTAINERIURN (Initial ONE of the following) An urn to be used as a container for the cremated remains has been purchased from and is described as follows: that if the urn is too small to hold the entire cremated remains, an additional rigid container may be used for delivery. (;;A)n rn is not yet purchased. I/We understand that if no urn is purchased or otherwise provided Pine View Crematorium will place the cremated remains in (Name of Crematory) a rigid temporary container for delivery. This Authorization Form was provided by Wendy M. Bulich was executed at (Funeral Doactar Name) Regan Denny Stafford Funeral Home (Funeral Home Name) 53 Quaker Road, Queensbury, NY 12804 (Funeral Home 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 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 17th day of March ,yp Robert O'Rourke c �-- Typed or Printed Name igna Address Typed or Printed Name Signature Address Typed or Printed Name Signature Address WITNESS: Wendy M. Bulich (Funeral Drector Typed or Printed Name) (Funeral Director Signature) 10441 egistretion u Stephen E. O'Rourke (Name of Deceased) DOS-1898-f(Rev. 08/15) Page 3 of 3 Pine View Cemetery & Crematorium Quaker Road Queensbury, NY 12804 (518) 745-4477 or (518) 745-4476 FUNERAL HOME: REQUESTED RETURN TIME: NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS: NAME: --- --CASE # �- /Z- DATE OF CREMATION: 3-1 9'Z0Zv TIME STARTED: _�1 TIME COMPLETED: 1V " TYPE OF CONTAINER: �h� � �✓ G� raw �� ��j �� PLACED IN RETORT: MOVED: . PLACE OF DEATH: ESTIMATED WEIGHT OF REMAINS AND CONTAINER: DATE & TIME REMAINS ARRIVED AT CREMATORY: PLACED IN HOLD: PLACED IN REFRIGERATION: .-__ RETORT # IN WHICH REMAINS WERE CREMATED: _ DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS FROM TIME OF ACCEPTED DELIVERY: NOTE: THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.