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Welch, John P. F'inQ View Cemetery 8, Cr-c:fYtr..)tor"iuni Quiiker ►<oacl Qucset151)ur'YI NY -I2804 ( J .18 ) 745-414177 Or• (,i .10) 7 45- 4476 FUNf"Rnl HOME.: . . �t 1 f . IZCTURN TIME: DATE Q TIME. E:REMA(N ARltiv . . EUAl' C..rtt:: Mn1 U1{Y: IZ NAME OF FUNERAL htrtt_c: l OR AI/70z �� Oft ItFC1lI ; T'rrtt:`Ii 111 S I O ry ni 1 D _._.. . Go NI) �l IV[1{ING RAM ��l nlNs: NAME: hbfiio 1,44C1,1 TYPE Or CON'r CASE !r /J n I N(:_It: �U rt>`{(1 C� .. .. f-ciIu/- - 21�- I. PLACE OF °EAT t-I: lip DrIeCil tlf513--/ 1,10) . .i SC!".(._.C).4`/ :_ /C.R1 f< .......... ESTIMATED wElGlf r or REMAINS ....__ Q CONTAINER .`-. �Z. PLACeO IN 7IO /l hlOE_E): ......... .. . .... ........... . PLACED IN rtrF KIGL:r.n'r. CREMATION: .. .. _. _. . DATE OF IZ ./5 I ZO 1 76-po TIME STARTED: PLACED IN t:1 ()rt'r ) .vQ 1I _ _ z,20 PO ftCTOR'r rr IN WIItCl1 I{LMAtNS W - ' 2 h WERE GI{CMA 1.CD: � t �. - . . {°wE2 nIl.EO REASON FOR f)I-Ll1Y I1 111=MntrvS wI_rtl: ' CEpTED ()I-.1.1v[rtY CREMATE() MORE THANHOURSFROM 1IME Or n(; ........................ . .............. .. NOTE: TItP Cltl _ _. . ._ 'Ml1.LIC)N . ... LOG SI1/11.1. Ilr at r111N.0) IN Ill t r I.IfMIINL:N7 1'I1..Ci or TIi Ei CIt(;M!\1 UrlY '_ New York State of NEW YORK Division of ° °°�°F CEeMEf nt ER STATE OF One Commerce Plaza OPPORTUNITY_ Cemeteries 99 Washington Avenue Albany,NY 12231-0001 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: l'Z I i t( f Number. /3 D 5- crematory Name:Pine View Crematory/n Address: Zi' ©U Itt M1OprO 0' 11101 Phone: PO 7VC-1(�� 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 minima)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: 4N P it)dC / / ,/ Marital Status: ,'YJAel/ Last Known Address: // .1. 1- z7' /ilea-Jc7 ic) tJ 7 �clr 1 hA/�c I(IL /,7U Place of Death: /6 hee I /7e tit0,✓ (0�' 3`4r0-9zJ A fi &76) Sex: M ❑F Age: 79 DOB:6 3/i.s/1 7,5 C Date of Death:as/.I3/ ce Estimated Weight a/d Description of casket/container in which remains will be delivered. .oIeR c c. C h t47iO c' COATTI,wr,- P7/0-€_ 1 j N PERSON IN CONTROL OF DISPOSITION (Person(s)in control of disposition,initial ONE of the following) I am/W re itfnated�ont of the_eased design in wilt ..men instru�executed pursuant to Public Health Law Secli 4201. R- /L114-) I ve edge decea a rsuant to Public Health Law Section 4201 or a will containin ' ns for the sition of ' er remains and I/we are the person(s)having priority under Public Health Law Section 4201 nd have the right to authorize cremation of the remains of the deceased_ MylOur relationship to the deceased is as follows: 4—e‘t) ^' d(Name neceased) DOS-1898-f(Rev.08/15) Page 1 of 3 Authorization for Cremation and Disposition (Insert from tt2 list below) Number. Description: SE)r 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\ ALL THREE of the following) {<J UWe hereby affirm that the body of the decease‘not not contain a 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 these items prior to cremation may result in harm to the crematory and crematory personnel. f `'J IlWe affirm that instructions have been given to c—��'4 N j/Vadme) 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 (Crematory Name) is not responsible for the removal of personal items from the container or from the remains of the deceased. Personal items left in the container or with the remains will be destroyed by the cremation process and cannot be retrieved after cremation. f'C^A' IIWe hereby authorize Pine View Crematory (CremalpyName) 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:Any Staff from the Edward L Kelly Funeral Home Address: US RL 9 PO Box 548,Schroon Lake,NY 12870 Phone:518532 7177 The cremated remains of deceased will be disposed of as follows: 1^0.1 le /41 p ry P f/N iovic If for any reason the person named above does not take possession of the cremated remains, Pine View Crematory is authorized to give possession of (Crematory Name) the remains to Edward L Kelly Funeral Home by delivery (Funeral Name Name) in person or by registered mail. `A";41., P, tt.)4c:_k, of DOS-1898-f(Rev.08/15) Page 2 of 3 r Authorization for Cremation and Disposition (Initial the following) 1` (1 I/We understand that if the remains are not claimed within 120 days of cremation, Pine View Crematory may dispose of the remains in (Name of Crematory) an irretrievable manner,such as by scattering. CREMATION CONTAINER/URN (Initial ONE of the following) Wi•-(1 /1 An urn to be used as a container for the cremated remains has been purchased from and is described as follows: Edward L Kelly Funeral Home biAir- -- 0 �r4 -j< � /j4 S` )L INVe understand that if the urn is too small to hold the entire cremated remains,an additional rigid container may be used for delivery. -OR- - is no y- •urchased. 1j - and- t=nd r ,t if no urn i- = rcha or otherwi - •..vided ' Ni; will place the cremated remains in (Name of Crematory) a rigid temporary container for delivery. This Authorization Form was provided by i d hat - -ai 7 was executed at (wr�eraI1 mclorName) / Edward L Kelly Funeral Home 1019 US Rt.9, PO Box 548 Schroon Lake, NY 12870 (Funeral Home Name) (Funeral Home Address) and is signed by the funeral director as witness to its execution. Uwe have received a completed copy of this Authorization Form_ Theperson(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 authorize(s)the foregoing. Signed this /M day of O.e - ,20 PD e -. - Typed or Printed Verne � Signature \lc, -6c a�` Ve&i\c, .k-Le A �.re,-;. „ A,-c.-�_ sr U. , IZ�I C.)Address Typed or Printed Name Signature Address Typed or Printed Name Signature Address WITNESS: (Fun rill oitt torTipeuorwmfBd Name) Signature) 6tiU P ' 1C� (Nmne of Deceased) DOS-1898-f(Rev.08/15) Page 3 of 3