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NEW YORK New York State
Division of Department of State
STATE OF DIVISION OF CEMETERIES
OPPORTUNITY. Cemeteries One Commerce Plaza
99 Washington Avenue
Albany.NY 12231-0001
Telephone:(518)474-6226
Authorization for Cremation and Disposition www.dos.ny.gov
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date: 12/17/2020 2 2'�
Number: J
Crematory Name: Pine View Crematory
Address:_
Phone:
21 Quaker Road, Queensbury, NY 12804
(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 info 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
1 - %
Name of Deceased: Craig 'Schultz
Marital Status: Divorced
Last Known Address: 237 Glenwild Road, Middle Grove,NY 12850
Place of Death: 237 Glenwild Road, Middle Grove, NY 12850
Sex: J M 0 F Age: 69 DOB: 06/23/1951 Date of Death: 12/13/2020
— --- Estimated Weight: r7
Description of casket/container in which remains will be delivered. ((
Florence Casket Company (Cardboard Box w/wooden Base)
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
Health Law Section 4201.
-OR-
INVe have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or
will containing directions for the disposition of his or her remains and I/we are the person(s)havinga
Law
Section 4201 and have the right to authorize cremation of the remains of the deceased. My/Our relationship to the Publicdeceased is as
follows:
Craig& rrSchultz
(Name of Deceased)
Jo..s.t S
DOS-1898-f(Rev.04/20)
Page 1 of 3
Authorization for Cremation and Disposition
(Insert from the list below)
Number: 5 Description: Jennifer Walsh(Sister)
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).
(Initial ALLTHREE of the following)
'v v// I/We hereby affirm that the body of the deceased does not contain a battery,battery ry 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
these items prior to cremation may result in harm to the crematory and crematory personnel.
1N/ I/We affirm that instructions have been given to Rolland G. Hoag
(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. Pine View Crematory
(Cremaory Name)
is not responsible for the removal of personal items from the container or fromm the remains of the deceased. Personal items left in the
contaiinerroo with the remains will be destroyed by the cremation process and cannot be retrieved after cremation.
IfWe hereby authorize Pine View Crematory
(crematory Name,)
to cremate the remains of the deceased.
(Initial OPTIONAL)
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 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 from the crematory is:
Name: Compassionate Funeral Care
Address: 402 Maple Ave.,Saratoga Springs, NY 12866 (518)584-4844
Phone:
The cremated remains of deceased will be disposed of as follows:
Return to Family ^�
If for any reason the person named above does not take possession of the cremated remains,
Pine View Crematory
(Crematory Name) is authorized to give possession of
the remains to_ Compassionate Funeral Care, Inc
(Funeral Home Name) by delivery
in person or by registered mail.
Craig.13een Schultz
(Name-of Deceased)
DOS-1898-f(Rev. 04/20)
Page 2 of 3
Authorization for Cremation and Disposition
(initial
the following)
J--A " I/We understand that if the remains are not claimed within 120 days of cremation,
Pine View Crematory
(Name o/Crematory)
an irretrievable manner,such as by scattering. may dispose of the remains in
EMATION cQNTAJNE RJ�URN
(Initial ONE of the following)
1 rV/ An urn 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.
OR- SC OCW-e c b oX
An urn is not yet purchased. I/We understand that if no urn is purchased or otherwise provided
Pine View Crematory
(Name of Crematory) will place the cremated remains in
a rigid temporary container for delivery.
This Authorization Form was provided by Rolland G.Hoag
(Funeral Director Name) was executed at
Compassionate Funeral Care. Inc
(Funeral Home Name)
402 Maple Ave.,Saratoga Springs, NY 12866
!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 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,orm and uth ze(s)the foregoing.
Signed this 17th December
g day of 20 20 s
Jennifer Walsh Cr
Typed or Pnnied NamB
6933 82nd Ave., North, Pinellas Park,FL 33781 Si_una:::.2
Address
•
Typed or Panted Name
Signature
Address
Typed or Printed Name
Signature.
Addresc ___...._-------_--
WITNESS:
Rolland G.Hoag
•
(Funeral Director Typed or Printed Name)
11636 (Fungi Erector Signature
(Pegis(ratroll Number)
Craig D,.0,r Schultz
(Name of Deceased)
UY1r\e_..S
DOS-1898-f(Rev.04/20)
Page 3 of 3