Liimatainen, Alan F' tfl(? V I e vv
C NIIIe C0I•.Y & C I'
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QLIt!('I)sI)UtY, NY 120041
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New York State
NE1I�f YCIRKivr .e of cement of State
STATE ofI�IMISrt7N OF CEMETERIES
oppoRTUNfTY_ Cemeteries One Commerce Plaza
w.s� i 99 Washington Av.enue
Albany.NY'223t-0001
re!epnane:(51$)4.74.622E
Authorization for Cremation and Disposition mow„wasnyAvv
Thus Authorization Form must be eomptnted and signed prior to delivery of remains for cremation.
Date:December 21,21120
Number 000
Crematory fame;Pine View Crematory -- -- __ _Address;2f Quaker Road,Ckuen9nsaalry,•VY 12804
Phone; 518-745•4477
i CREMATION IS AN IRREVERSIBLE AND FiNAl.PROCESS.
Cremation is carried out by piecing the remains of the deceased and the container balding the remains into a cremation chamber where+
they are subjected to intense heat and fame. The heat arid flame will incinerate and consume everything except hone and metal,i
I which ere ell that will be left after cremation.
Following cn rnetlon,the crematory wilt take reasonable efforts to remove alt of the remains and other material from the cremation
chamber,but some minimal dust and residue will likely be left behind. The crematory+sill separate incidental and foreign material from
the remains and the incidental acid foreign material will be rfispo'ed of as required by law, The cremated remains will be mechsnicalr iy
pulverized into small pieces and placed into a designated container or urn, Cremated remains generally are pulverized until no
;ink fragment is recognizable as Owlets/tissue_
QPENINO OF THESONT14jNE t
Thu crematory may only open the container holding the un-cremated human remains in limited ircumstances,such as to confrrn the
identity of the deceased or to ensure that no material is enclosed whicti might in;u,e employees or damage the crematory property if
human remains are delivered in a container which is riot suitable for cremation such as ceremonial or rental casket_the
crematory will require that the remains be moved into d suitable container before it accepts the rsrraine. The opening of a
container or the transfer or removal of remains will be conducted oeforia a witness and will be done iri privacy,with dignity and respect.
IDENTIFICATION N OF R,CE C6
Name of Deceased-Alan i-iimatai!ren Widowed__Marital Status;
Last Known Address:, 3l rl� r/kd y I �,-. \ )1 _ 1 2.c`�" �{
miser or Death: -------Si/6 l��> `y 1! t� S ti�' u i/
Sex: en M C F Age:61 tom;09-•23-1959 _Date of heath:_ 17-1\ 7 r� �_.O Esbrnatesd Weight: )41'
Description of casket/container in which remains wiltoe delivered.
Minimum Cremation Casket, Florence Casket Co. Cardboard/Pine
PERSON ty GONT)SQL OF Dr/POEM(Per'son(s)in conbnp of dispoehkxt,Olio!ONE at the following)
I am/Wo are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
Health Law Section 4201.
-OR-
.
'•�yr
; '' z rv? e have no knowledge that the dece to act executed a written instrument pursuant to Public Health liar Section 42R1 or a
will.. : ning directions for the disposition of his or her remains and I/we are the person(s)haaving priority under Public tfeelth Law
Secton 4201 and have the right to authorize cremation of the remains of the deceased. My/Cur relationship to the deceased is as
foflcwe:
Alan Liimatainen
DOS-t898.I(Rev.04120) Page 1 of 3
Authorization for Cremaktioin and Disposition ,
(lased f 1 m the,1st below) •�.� —-- ��
Number._ Descripeor Any serve/legchild eighteen yrsrus of age Or oldery
1. A person designated in writing pursuant to Pubic Health Law Section 4201(3);
2. The surviving spouse;
2xr The serve/erg domestic partner,
3. Any sunt$ving child eighteen years of age or elder;
• 4. A surviving natant;
5. A surviving sibling eighteen years of age or eider:.
6. A lawfully appointed grdian;
7. Any c rsores;eighteen years of age or Older entitled to share in the estate and who Ware dorsst in relationship to the deceased;
8. A duly appointed fidduciary of the estate:
9. A close friend or relative who has executed a wntten statement pursuant to Public Health Law Section 4201(7);
te. A chief fiscal officer of a county or a public administrator-appointed pursuant to the Surregaate`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
taw Section 4201(7).
(g art ALL T REE of the following)
,/
i/We herebyaffirm that the
body of the decrse.,eC does not contain a battery,battery pack power Deli,rat(rC•dctivr;imlplant.
or red'.=ctive device and teat any such materials were removed prior to the execution of this Au/rartzatfon Form. Failure to remove
these items prior to cremation may result in harm to the reematory and crematory personnel
Ste Gilman
• '"'` UWe Arm that instructions have been given to °ie —• _
Ii ing the removal.of any personas property or otter thing of value which any person signing below or any family member of the
decreased wishes to preserve. Pine View Crematory
jrrvndtrGNa e.)
is net renponSibie 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 the3 cremation process and cannot be retrieved after c remeatiort.
a Pine View Crematory
:e." Me i+r:reduy authorize_._._.__..-.__________._W_-_ �_.._.._�
(owlet!),iJer m)
to cremate the remains of the deceased.
(Initial OPTIONAL)
ewe 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 emend this form to provide the correct name and
eddrees of such alternate crematory.
FINAL Dtt3PO$i oN
The person authorized to receive the cremated remeine of the deceased tern;the'remstory is:
Name:Mt_Kilmer Funeral Home
Address: 82 Broadway, Port Edward,NY 12828 518-747-9266
The cremated rernalne of deoeased will be disposed of as follows;
Mailed to dies Litrnateieen,7 Church Street,North Bennington,VT 05257if for any reason the person named above does not take possession of the cremated remains,
Pine View Crematory is a..r_dorized to give possession of
eeerertee eerie
the remains ter MMB_Kilmer Funeral Home
by delivery
(Amara loins Aran*
in person or by registered mail, Alen Liimetainen
DOS--1888-t(Rev.04120) Page 2 of 3
Authorization for Cremation and Disposition
(initial the&vo ing)
<. e understand that if the remains are not claimed within t20 days of cremation,
Pine 'ew Crematory
may dispose of the remains in
+Name dr)ariagool
an irretrievable manner,such as by scattering.
• CR ION callAMMARLs
(Initial ONE of the following)
An urn to be used as a container for the;remeted remains has been purchased from
and is described as foNows:
Uwe understand that if the urn is too small to hold the entire cremated remains,an additional rigid container may be used for delivery
-OR-
,
r, er7e'An um is not yet purchased. Me understand that if no urn is purchased or otherwise provided
Pine raw Crematory
INemeaiCen910wt -.._ will place the cremated remains in
a rigid temporary container for delivery.
This Authorization Form was provided by Stephanie Oilmen
.------,-- .was executed at
(F>raml oironar yore)
M.B.Kilmer Funeral Home
__—._.._._. ,�....__. (Rowel Herne Nan*
82 Broadway,Fort Edward,NY 12828
v .. emend Home M111r9591
and is signed by the funeral director as witness to its execution.
t/We have received a completed copy of this Authorization Form_
The person(s)identified below islere the person(as)in control of disposition,who by signing this Authorization Form,attest(e)
to the accuracy and completeness of the information contained in this Auhrorization Form and authorize(s)the foregoing.
Signed this day of \v"' Zt3_ ____.
Jesse lilmaheinen ,_
xypWarPnMe-r11ieR.B "" ---- •... ass:.. ,_._,
7 Church Street.Moth Bennington.VT O5257
Aothiaa
Jeremy Liimatainen a
Typed af NOM None
•
Moped ai f 48 NrMM riatiare
Address
WITNESS:
Stephanie A.Gilman i. A, C�-..
!Rums'Dn7abr Tio.0 a•bnnbd Nan.) „f rrcror ny `. ,•`.
14183
(R69revYfe Mrmap)
Alan Liimetainen
(Narar or Neve:0 •�
DOS-18984(Rev.04/20) Page 3 of 3