Altman, Idar „, • TOTIN OF QUEEN,SBURT
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Date of Cremation �c C Z(, 1010
Time Cremation Started
g= ice ,l}h
Time Cremation Completed jU < aU �
Type of Container
?emarks :
r
vt.,6 110
9 . 40 4
/b�10�'
I am/we are the person(s) having priority under Public Health Law section 4201 and have the right to authorize
,cremation of the remains of the deceased. My/Our relationship to the deceased is as follows:
(Insert from the list below) II-- d.eoji't
II,, ��pp ,�, -Number: 10Q Description:QuA(o4& ' (AM- tb VIjZ�IQ�U. •06Ky/ �
1. A person designated in writing pursuant to Public Health Law section 4201(3); I
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§4201(7);
10. A chief fiscal officer of a county or a public administrator appointed pursuant to the Surrogate's Court
Procedure Act;
10.. Any other person who is acting on behalf of the deceased and who has executed a written statement
pursuant to Public Health Law§4201(7).
(Initial ALL THREE of the following)
4 &12, I/We hereby affirm that the body of the deceased does not contain a battery, 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. oo
1 I/We hereby affirm that instructions have been given to (funeral director name)0Qt 16 Qethe f t
regarding the removal of any personal property or other thingyaluq,which any person signing elow or any family
member of the deceased wishes to preserve. (crematory name) Ile \JJI ells C ttua..3 rc,1,4.444 is not
responsible for 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.
04-K I/We hereby authorize (crematory name) I i2t�(,nY1:Jwcit�`�Y�t 1tWl_ to cremate the
remains of the deceased.
FINAL DISPOSITION
The person authorized to receive the cremated remainsn of the deceased from the crematory is:
Name: ' J Q.�t Ic A t ti k40A412
Address: 5-3l:Zktakeir j ._• l,Lfee1401 kt 1', !Jy Phone: 3(23 f 2-6(Z7
The cremated remains of deceased will be disposed of as follows:
TZ��I.t OZIJ `�O -re.1 —
If for any reas.jn the pprson amed above does not take possession of the cremated remains,
(crematory name)-I rrie Y I 1mm. is authorized to give possession of the remains to
(funeral home name)1Z Q.1,t lLu d lbeaut �it.� V+o r�-�- by delivery in person or� by registered mail.
TDA
DOS-1898-f-I (Rev.01/10) Name of Deceased Page 2 of 3
!Initial the following)
fg_k__I/We ersta 9d tha if the r mains are not claimed within 120 days of cremation,
(crematory name) Nr e VI VU/1/1 may dispose of the remains in an irretrievable manner,
such as by scattering.
CREMATION CONTAINER/URN
(Initial ONE of the following)
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-
f<PrK An urn has n.o,yet been purchased. I/We understand that if no urn is purchased or otherwise provided
(crematory name) C.N V i-fJcirumgazkirvi,vt. will place the cremated remains in a rigid temporary
container for delivery.
This Authorization Form was provided by (funeral director name)0-01,3l3lr; L —was executed at (funeral home name) '- N
I l
(funeral home address)SS �jiA-kizh�r'_� , , IJ (wet and is signed by the funeral director
as witness to its execution.
Y
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 day of ' '1 - , 20 ( 0 .
,j4T14 1Z14bCA..,Pe:- f e�
Typed or Printed Name E- ( Signa
C J i ( 5 &ke ; oirt,Ce �eorgE , NY (z&�s- '
Address JJ
Typed or Printed Name Signature
Address
Typed or Printed Name Signature
Address
WITNESS:
3301316 L. C�uG7Ez�
Funeral Director Typed or Mrinted Name uneral Director Signa re
DI14Uf
Registration Number
Thlk -AiTivu rt..) .
DOS-1898-f-I (Rev.01/10) Name of Deceased Page 3 of 3