Stoddard, Antoinette (2) Authorization for Cremation and Disposition
(Insert from the list below)
Number: 3 Description: Daughter
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 ,:losest ii 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 Sect on 4201(7);
10. A chief fiscal officer of a county or a public administrator appointed pursuant to the Surrogate's Curt Procedure Act;
10a. Any other person who is acting on behalf of the deceased and who has executed a written stateme it pursuant to Public Health
Law Section 4201(7).
(Initial 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
th a trams prior to cremation may result in harm to the crematory and crematory personnel.
INVe affirm that instructions have been given to Ronald Schnepf
(Funeral Director Name)
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.
Pineview Crematory
(Crematory Name)
is not responsible for the removal of personal items from the container or from the remains of the tleceasect Personal items left in the
ci er or with the remains will be destroyed by the cremation process and cannot be re:rieved after cremation.
e
IlWe hereby authorize Pineview Crematory
(Crematory Name)
to cremate the remains of the deceased.
(;d i,/,P PTIONAL)
/r
dv I/we hereby authorize the named funeral director to provide for delivery to and cremation by an alternate
crematory,If deemed necessary in the opinion of the funeral director,and to amend this fo In to provide the correct name and
address of such alternate crematory.
FINAL DISPOSITION
The person authorized to receive the crematedll remains of the deceased from the crematory is:
Name: .?4 re-u 4' 4-Ui1lc r(,L I C vYJ_ ( n p \,
Address: a4 NU( j.--� i' , Phone:S D (0(D t).T7 Li 7
The cremated remains of deceased will be disposed of as follows:
rt--f Lr +0 -9J MI I y
If for any reason the person named above does not take possession of the cremated remains,
Pineview Crematory is au horized to give possession of
(Crematory Name)
the remains to Mckeon Funeral Home by delivery
(Funeral Home Name)
in person or by registered mail. Antoinette Stoddard
(Name of Deceased)
DOS-1898-f(Rev.04/20) Page 2 of 3
Pine View Cemetery 8, Crematorium
Quaker Road
Queensbury, NY -12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME:
TIN t Mo £oN sops TrC.R E T U R N TIME,
DATE & TIME REMAINS
ARRIVED AT' CREMAIORY:
NAME OF FUN _ .. OIfYIZO �l,JS
ERAL DIT2t✓C FOR OR REGRISTERED RESIDENT DELIVERING
VERING REMAINS;
_ rrY Mz _
NAME:
...NTr_ PE ... STogOlairD
CASE ,r 111
TYPE OF CONTAINER:
. . . ................
P
LACE OF DEATH: WI( S. _... _..
( Klullitl _ ,._.. za3L
.................
ESTIMATED WEIGH F OF REMAINS & CONTAINER
Acr-
PLACED IN HOLD:
... ....... . ................... .... .........
............
PLACED IN REFRIGERATION: ------
DATE OF CREMATION;
/ IS]Zp
I
TIME STARTED: q ---
44 TIME COMPLETED: 12 JS^
PLACED IN RETORT:
1 ysrin . . MOVED: ..
30 1I a:Wet/
. ................ ...
RETORT 11 IN WHICH REMAINS WERE CREMATED: MM __.
_...
� urt-2
DETAILED REASON FOR DELAY IF REMAINS wENE CREMATED
FROM TIME OF ACCEPTED DELIVERY: MORE THAN qa HOURS
.. ... ......... .. .................
---
NOTE: THE CI MAT'ION LOG SHALL DE Rl:'FAINLO IN THE PEIlM/1NENT ri c OF THE CREMATORY.
1-
New York State
Department of State
ri—INEW YORK Division of DIVISION OF CEMETERIES
STATE OF One Commerce Plaza
OPPORTUNITY_ Cemeteries 99 Washington Avenue
Albany,NY 12231-0001
Telephone:(518)4746226
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:10/14/2020 Number. I I
Crematory Name:Pineview Crematory
Address:21 Quaker Road O i o S� �'j,;0l� 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 incider tal 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 cir:umstances,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 ceremonia 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 don a in privItcy,with dignity and respect.
IDENTIFICATION OF DECEASED
Name of Deceased:Antoinette Stoddard Marita Status: Widowed
Last Known Address:405 State Route#22 Granville New York 12832
Place of Death:405 State Route#22 Granville New York 12832
Sex: ❑M El F Age:91 DOB: 05/02/1929 Date of Death:10/11/2020 Estimated Weight: 150
Description of casket/container in which remains will be delivered.
alternative container
PERSON IN CONTROL OF DISPOSITION
(Person(s)in control of disposition,initial ONE of the following)
I amNVe 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 nof knowledge that the deceased executed a written instrument pursuant tc Public Health Law Section 4201 or a
wil containing directions for the disposition of his or her remains and I/we are the persons)havinc 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:muG N7T2i:
Antoinette Stoddard
(Nacre of Deceased)
DOS-1898-f(Rev.04/20) Page 1 of 3
Authorization for Cremation and Disposition
(Inni e following)
` : I/We understand that if the remains are not claimed within 120 days of cremation,
Pineview Crematory
may iispose of the remains in
(Name of Crematory)
an irretrievable manner,such as by scattering.
CREMATION CONTAINER/URN
(initial 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 urn is too small to hold the entire cremated remains,an additional rigid container may be used for delivery.
-a)
An urn is not yet purchased. I/We understand that if no urn is purchased or otherwise provided
Pineview Crematory
will pl ace the cremated remains in
(Name of Crematory)
a rigid temporary container for delivery.
This Authorization Form was provided by Ronald Schnepf
was executed at
(Funeral Director Name)
Mckeon Funeral Home
(Funeral Home Name)
3129 Perry Avenue Bronx NY 10467
(Funeral Home Address)
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 and autnorize(s)the foregoing.
Signed this 13 day of October 20 20
Andrea Stoddard ��
Typed or Footed Noma Z N��:—..„...2.....„Vr ��
405 State Route#22 Granville New York 12832
Address
Typed or Prnted Name Signature
Address
Typed or Printed Name Signature
Address
WITNESS:
Ronald Schnepf xa
/ ,
(Funeral Director Typed or Printed Name)
(Funeral Director Signa we)
13959
(Registration Number)
Antoinette Stoddard
(Name of Deceased)
DOS-1898-f(Rev.04/20) Page 3 of 3