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wbury, NY 12.801
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Now York Orate
NEWYORK Division of
<2.,
STATE OF
OPPORTUNITY.
Cemeteries Department of State
DIVISION OF CEMETERIES
One Commerce Poza
49 Washington Avenue
Mosey,NV1224147001
Tefephone fbla}4744225
www dos onion
Authorization for Cremation and Disposition
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Dal,1 V24/2020 i2.51
Number
c,.,,,,v,wy Name P ne View Crematorium
Acw„,„_Quaker Rd,Queensbary,NY 12804 Ph —le 2 isq 5 - cti el 7 7
Phone .>
,........._ ,
_ —
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS i Cremation is carnet,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 bons and metal,
which are all that will be left after cremation.
Following cremation,the crematory wrtl take reasonable efforts to remove all of the remains and other material 40kb the ciernabon
i chamber,but some minimal dust and residue will likely be left behind The crematory will separate Incidental and foreign materiel from
the remains and the mmdental and foreign material will bo disposed of as required by law. The cremated remains wri be mechanically
Ipulverized nto small pieces arid 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 landed 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 cooduoied before a witness and will be done in privacy,with dignity and respect.
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IDENTIFICATION OF DECEASED- ) i. t f ,, (,I .
Jettenreenson )
Name of Deceased-- Marital Status Single
Riverside Center for Nursing arid Rehab 90 North Main St..Castleton-on Hudson,NY 12033
Last Known Address
Place of Death Riverside Comer for Nursing and Rehab 90 North Main St.,Castleton-on Hudson,NY 12033
See
El M
0 F Age t. ,. Doe. "...;_r ; J Date of Death 11/24/2020 Estimated Weight,
Description of casket/container;r1 which remains will be delivered
Matthews Casket Co.Cremation Case-cardboard top,plywood bottom
.,........ ...
PERSON IN CONTROL OF DISPOSITION
(Persoh(t)on .oho/of disposition,root ONE of the following)
art/et are the designated agent of the deceased designated in a will or written instrument executed pursuant to Pubes
Hearth Law Sector 4201
Li i/We have no trloyaedge that the deceased executed a written instrument pursoant to Path,:Health Lew Section-1201 or a
MO contafmng cl recbors for the disposition of his or her remains and Owe are the personfs)having priority under PubSC 14eatth Law
Ser,Son 4201 and hare 910%PA to authorize cremation of the remains of the deceased My(Our relationship to the deceased is as
follows
'fl( (d ..!/ l /
Jaffery ung n
DOS 1 e,944(Rev 04120) Page 1 of.3
vo.......... .....MolaalinillIMMINEMOMIIII
Authorization for Cremation and Disposition
tinsel from the est below)
6
-DesulPticol /
1 A Colson d" sated
2 T `0 wrlhng Pursuant to Public Health Law Section 420/(3),
e surviving spouse,
32a. T.Te sunrvicg domestic partner
Any survivirg chid eighteen years of age or elder
4, A surviving parent
5 A surviving stbing etgreeen years of age or older
6 A lawfutty appointed guardian.
T Any person(s)eighteen years of age or elver entitied to share or the estate and who isfare closest in relationship to the deceased,
8. A duty appointed fiduciary of the estate,
9 A close trend or relatrye who has executed a written statement pursuant to Pubic Health Law Section 4201(7),
10- A chef 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 eereen statement pursuant to Public Health
law Section 420i(7).
fr.t.a,ALL THREE of the followleg)
L'We hereby&rem that the body of the deceased does not rontan a battery,battery pack power cell,radioactiveCo implant,
radioactive device and mat any such matenals were removed poor to the execution of INS Authorization Form, Failure to remove
these items prior to cremation may result In harm to the crematory end crematory personnel,
- ,
r Mara K.Parish
Lnt hale affirm Mat est/options have been given to
liej* (how+Droew Va.nel
regarding tne removal of any personal property or other thing of value which any person signing below or any famay member of the
Pete View Crematortum
deceased wishes to presetve,
Www/
is not responsible for the removal of personal items from the container or from the remains of the deceased Personal items left In the
k container or..yrith the remains will be destroyed by the cremation process and cannot be retrieved after cremation.
3 Poe View Crematorian
Mc A I Me hereby authorize
dier-
to cremate,the remains of the deceased.
iltabal OP TiONAL)
Uwe hereby authorize the named funeral director to provide for delivery to and cremation by en alternate
crematory,If deemed necessary in the opinion of the funeral director,and to amend this form to provide the correct name and
address of such alternate crematory.
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased horn the crematory is
Carleton Carteret Home,Inc
Address 68 tram St.Hudson Falls,New York 12839 5187474243
The chaimatect rermairm of deceased will be d sposed of as follows
Earthen Burial at St Mar/s Cemetery n the tom)of fen Edward
If for an/reason the person named above does not take rabiesesson of the cremated remains.
Pore Vane Crematorium is authertzed to give possession of
71w:eat,
Carleton Funeral Herne,tort * by delivery
persc.,o,CS by recouveg mad Jcidery Denson
Oimo Atouteirea
PAge 2 of 3
12,14/ 1
_ _
a
Authorization for Cremation and Disposition
omttai'he toil
understand that if the remains are not claimed within 120 days of cremation,
nine View Crematonum
may dispose of the remains in
rw
an krretnevabie manner,such as by scattering. W
CREMATION CgNTAINERJURN
itn,(;af ONE of the firlowing)
An urn to be used as a container for the cremated remains has been purchased from
and s describe°as follows'
-die understand that if the urn is too small to hold the entire cremated remains,an additional rigid container may be used for delivery.
CR-
.�(An urn is not yet purchased. INVe understand that a no urn is purchased or otherwise provided
Pine View Crematorium
will place the cremated remains In
peweiroemiiim
a rigid temporary container for delivery.
This Authorization Form wasprovided byMark K.Parish
_.._.._was executed at
fr...nt c>~..raMin.t
Carleton Funeral Home,Inc (Anent Wm*Nam.0
68 Main SI.Hudson Fads,New York 12839
F�N«w.wm.•ea..ri
and=s signed by the funeral director as witness to rts execution
L'We have received a completed copy of this Authorization Form.
,The person(*)identified below isiare the person(s)In control of disposition,who by signing this Authorization Form,attest(s)
l to the accuracy and completeness of the information contained in this Authorization Form and authorizes)the foregoing.
t 'CPS-i
is y=) November 20
'� _S�Oscthis_ day of
Arta PM„ps e )
42_Br; & QAz my l 01 -41
WITNESS
Mark K RerV`
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Jeer/0enson S
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