Irizarry, David New York State
NEWYORK Division of oepartmewofState
DIVISION OF CEhWTSRIES
STATE OF One commerce Ante
OPrORTthhIiTY. Cemeteries 99 Washington avenue
Abany,NY W31-0001
Telephone:(51447*6226
www.dos.ny.gm
Authorization for Cremation and Disposition
This Authorization Form must be com~and signed prior to delivery of ref wins for cramadrin.
Date:4/27/2020 _ Number:_ S n n
Crematory Name:
Address Phone:
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS. l
Cremation is carried out by plating 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 wip kwAneraW 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 cxher 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 smaw pieces and placed into a designated container or um. Cremated remains generally are pulverlaad urht8 no
single fragment Is recognleabla 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 ramalm ara d"wanwi in a rnnt*h~wh&v-h r:net 011MAM&M. 64—
IDENTIFICATION OF DECEASED
Name of Deceased: David Irizarry Marital status Divorced
Last Known Address: 1760 Lexington Ave Manhattan, New York 10029
Piece of Death:1760 Lexington Ave New York, NY 10029
Sex: ®M ❑F Age:39 DOB: 5/24/1980 Date of Death:4/18/2020 Estimated weight
Description of casket/container in which remains will be delivered.
wooden container
PERSON IN CONTROL OF DISPOSITION
(Person(s)in combo/of disposWDn, Yam' 1 ONE of the*ftw*V)
1 anVWe are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
Health Law Section 4201.
-OR-
Me have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
will oontehning directions for the disposition of his or her remains and Uwe are the person(s)having priority under Public Heab Law
Section 4201 and have the right to authorize cremation of the remains of the deceased_ My/Orx relationship to the deceased is as
fonows:
David Irizarry
David Irizarry
DOS-1898-f(Rev.08115) Schuyler Hill Funeral Home
TR050120_FH06/C09/048
Authorization for Cremation and Dls
Position
Onawt from the#at below,)
Number..
---_ Description: father
1. A Demon designated in writing
2. The surviving spouse; n9 iwmuent to Public Health Law Section 4201(3);
2a. The surviving
3. qnychidomestic
hPertner,
4. A ssurviving � teen years of age or older
u�+m ,
g parent;
A surviving sting eighteen
8. A years of age or older
lawful y appointed guardian; `.�.
�. Any Person(s)eighteen years
8• A duty appointed flducla of the Of�or older entitled to share In the estate and who Ware closest in relationship to the deceased:
9. A close friend or ry estate-
friend A chief fiscal relative you has executed a written statement pursuant 10a, An other sr el otvroer of a county w a Pubic administrator a to Public Health Law Section 420f
Law Section 4201who is acting on behalf of the deceased and who®s executed:Suant to the rrogate's Court Procedu)rs Ate Awl
( ) written statement Pursuant to Pubes itisalth
THREE of the fotlowyV)
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 Autho►Izat'lorr Form. Failure to remove
these items prior to cremation may resuh In harm to the Crematory and crematory personnel.
UWe affirm that instructions hays been given to Jeannine Carbone
regarding the removal of any personal property or other thing of value which any person
suing below or any family member of the
deceased wishes to preserve. Qtj
(19
Is not responsible for the removal of inn
Personal items from the container,or from the remains of the doomed, P91`30nah Items left In the
WnWW or wNh the remains WO be destroyed by the cremation process and cannot be retrieved an<ttr cremation.
��—VW*hereby audwrtze
to an Wnase the remains of tte deceased.
FMAL DISPOSITION
Tto person authorized to receive the cremated remains of the deceased from the crematory is:
Name:Schuyler Hill Funeral Home
Address: 3535 East Tremont Avenue Bronx New York 10465 Phone: 718-792-0270
The cremated remains of deceased will be disposed of as foikw4:
return to family from Schuyler Hill
If for any reason the person named above
dopes not take on of cremated remains.
Z V 1 C MAID, r qis authorized to give possession of
(a.m.eay rare}
the remains to Schuyler Hill Funeral HOMe by delivery
tt,.rr.irar,.nr.»/
in person or by registered mail.
Day" David Irizarry
DOS-18W4(Rev.08/15) Schuyler Hill Funeral Home
TR050120 FH06/C09/048
Authorization for Cremation and Disposition - -
ON"t#M*O
uwa understand Iif the remains we not wlom 120 days of cmrw*on,
may dWposa of the(rnsine In
�d d 0�1p1y)
an&ratrisvable Mwwer.such as by watterft. .
aaft ONE of to kAnWrig)
An um to be used as a contsiner for the airnalsd rerrneft tes been purchased tram
and is described as toibws•
Me understand that ff the um is too aural to hold the enure crernehed rerneft,an addWonal rigid corrtsirrar may be usd for
-OR-
M um is not purchased. UWe understand that 1f no um is purchased or otherwise provided
\ a WE pkwoe the a'www rsnrsiru m
prfw�day) .
a r1od temporary oonh finer for delivery.
This Aa/ffwdXNf/bn Form was provided by Jeannine Cflrbwi was mcec L tad at
n.�.va.arrr,rr.y .
Schuvler Hill Funeral Home _
3535 East Tremont Avenue. Bronx. New York 1 G465
M have racelved a computed copy of this AudxvhnfJon Form.
TM perso*s)Identfl bd below Mont 1M person(s)In conbul of disposition,wM by dpftq d is ALghwftwftn Fonw aft**)
i o the accu aw eorrrplabness fhe MMsrt+aNlon oomainsd b teals Jlraehonlzetlaw Fornn and autl�orM(s)falls#lors�polrg.
,signed thb-s�` '�--day of +
Eliou Irizarry I „�
3975 Sedgwick , Bronx, New York 10463
ANOM
wlrt#M:
Jeannhe Carbone
P%r^Woiooft orr�liratAlrey ,.r
l ew
uw.«1 - -
David
David Irizarry
Dos-18M4(Rev 0e/15) Schuyler Hill Funeral Home
TR050120_FH06/C09/048
Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: �GJnb+.11 1e� �'l��r RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: S S•UW 31i)V,-n
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME: D yi d CASE #
TYPE OF CONTAINER: LjOodB�t
PLACE OF DEATH: /'%oo I4 X L, ,4 , A tJ 2 /(1 14 N'/l0 Z�
ESTIMATED WEIGHT OF REMAINS S CONTAINER -7-5/D /6
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION:
TIME STARTED: QU( TIME COMPLETED: Z�
PLACED IN RETORT:
MOVED: ('
RETORT # IN WHICH REMAINS WERE CREMATED: Swr,41 R i-k
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.