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New York State
Department of State
TX-NEW YORK Division of DIVISION OF CEMETERIES
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: 01/02/2021 Number: 11
Crematory Name: , _ ,� �flI;JY"rJ (�f^'�' r0,-aa`-)
/�� lV
//ii�(nr„( w - • , Z Phone: S�b1 7h5'��r
Address: 1( l r 14 FA onto, ,itAvoti I ( J
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 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: Maureen Metcalfe Marital Status: Divorced
Last Known Address:353 Schroon River Rd., Warrensburg, NY 12885
Place of Death:Saratoga Hospital, 211 Church Street, Saratoga Springs, NY 12866
Sex: D M ® F Age: 75 DOB: 8/1/1945 Date of Death: 01/01/2021 Estimated Weight:a— Av
Description of casket/container in which remains will be delivered.
Alternative container— Matthew's Casket Co.
PERSON IN CONTROL OF DISPOSITION
(Person(s)in control of disposition, initial ONE of the following)
I a r_, - are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
He- °
-OR-
firsilW
/�'
"e haven• nowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
will c•ntaining directions or the disposition of his or her remains and I/we are the person(s)having priority under Public Health Law
Section 4201 and hay:- he right to authorize cremation of the remains of the deceased. MylOur relationship to the deceased is as
follows:
Maureen Metcalfe
(Name of Deceased)
DOS-1898-f(Rev.04/20) Page 1 of 3
Authorization for Cremation and Disposition
(Insert from the list below)
Number: 1 Description:Child
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. • •they person who is acting on behalf of the deceased and who has executed a written statement pursuant to Public Health
A
tion 4201(7).
'EE of the following)
("g
,e hereby affirm that the body of the deceased does not contain a battery, battery pack, power cell, radioactive implant,
• device and that any such materials were removed prior to the execution of this Authorization Form. Failure to remove
rems prio to cremation may result in harm to the crematory and crematory personnel.
---;,ri
i �w e a 'rm that instructions have been given to Cassidy VonStettina
` (Funeral Director Name)
regarding the re oval of any personal erty or other thing of value which any person si ning below or any family member of the
•-.--:- . ' to preserve. ( e � 1 e UJ � e CA L
` (Crematory Name)
is t res sible fo he removal of pe nal items from the container or from the remains of the-('eceased. Personal items left in the
n ' r or with the emains will be stroyed by the cremation process and cannot be retrieved after cremation.
`Y\Q I/We here y authorize \ir 1 )3 Ct-‘PIYVGL- tLi
(Crematory Name)
ate the remains of the deceased.
(Initial OPTION
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:Amy Metcalfe
Address: 341 South Main Ave., Albany, NY 12209- Phone: (518)488-7126
The cremated remains of deceased will be disposed of as follows:
Returned to family
any�r_eason the person named aboveabg1 does of take possession of the cremated remains,
t I l e - VI•P u C CX Y(3
is authorized to give possession of
(Crematory MIA
the remains to Regan Denny Stafford Funeral Home by delivery
(Funeral Home Name)
in person or by registered mail. Maureen Metcalfe
(Name of Deceased)
DOS-1898-f(Rev. 04/20) Page 2 of 3
A of :tion for Cremation and Disposition
• ti- +e followin,
1 I/We u d nd that if the remains are not claimed within 1 0 days of cremation,
Me v 1�- may dispose of the remains in
(Name of Crematory)
an irretrievab manner, uch as by scattering.
CREMATION CONTAINER/URN
(Initial ONE of the following)
Regan Denny Stafford Funeral
An urn to be used as a container for the cremated remains has been purchased from i..i, ,„,,
an scribed follows:
/We unde d tha if the urn is too small to hold the entire cremated remains, an additional rigid container may be used for delivery.
-O+,1, \ii(`(-\
P1,
" An urn s etpurchased`. I/We.understand that if nourn is
urrchased or otherwise provided
7 \r\•.€ V 1'�JV CresNlA3 will place the cremated remains in
(Name of Crematory)
a rigid temporary container for delivery.
This Authorization Form was provided by Cassidy VonStettina was executed at
(Funeral Director Name)
Regan Denny Stafford Funeral Home
(Funeral Home Name)
53 Quaker Road, Queensbury, NY 12804
(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 authorize(s)the foregoing.
Signed this 2nd day of January , =
Amy Metcalfe Ot(VLj lam- I
Typed or Printed Name : re V
341 South Main Ave., Albany, NY 12209-
Address
Typed or Printed Name Signature
Address
Typed or Printed Name Signature
Address
WITNESS:
Cassidy VonStettina
(Funeral Director Typed or Printed Name) (uneral Director Signature)
13709
(Registration Number)
Maureen Metcalfe
(Name of Deceased)
DOS-1898-f(Rev.04/20) Page 3 of 3