Sims, Mary Jane •
TOWN OF QUEEN,SBURT
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director "� /04
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Case
'Date of Cremation 5 , •-) ,' t
- ime Cremation Started
" =me Cremation Completed �, yS
' foe of Container C' r CrA ��Y � � c,o;t- oC ck
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S Department of State
Authorization for Cremation and Disposition Division of Cemeteries
One Commerce Plaza,99 Washington Avenue
Albany,NY 12231
(518)474-6226
www.dos.state.ny.us
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This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date: (S-7/7/ ; Z(/() Number: c2O'6— y lit a 3 )
Crematory Name: f'i N i=0/Z-t>✓ CR/'/`tf 7l 2iu/(
Address: 9/ ( to KK,e 44 1:,•11 6(tgy Ny 6M-- l y Phone: S/� 7YS`/�`)
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 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 crematory property. If human remains are delivered in a container which is not suitable for cremation
such as a 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 DECE SED
s---"
Name of Deceased: �3,s4 y ‘,J E JL _ci lei S Marital Status: /1/3102 is/0
Last Known Address: t63 / / ,,v.0%se r- eb'f� c,c,,z 13 i.:4j
9 Ai y ,' di
Place of Death: SA-k ry 6--f9 �,/�a / /
Sex: ❑M IF Age: ( DOB: •.(37 /9 iJ Date of Death: cii &L$ Estimated Weight: aob
Description of casket/contain in which remains will be delivered:
go-A--0/2-4 Li.-71,44_ :1-1:-...;Actiz-"L"-- -- .1,/,-SrS 774
PERSON IN CONTROL OF DISPOSITION
(P• on(s)in control of disposition,initial ONE of the following)
`r 4 I am/We are the designated agent of the deceased designated in a will or written instrument executed
•ursuant to Public Health Law section 4201.
-OR-
I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law
section 4201 or a will containing directions for the disposition of his or her rem ins and (Continued next page)
,i9ky R L gill
DOS-1898-f-I (Rev.01/10) Name of Deceased Page 1 of 3
I am/te 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/Ow'relationship to the deceased is as follows: ` ,,
(Insert from the list below)
Number: Description: g lZci i Gri,.,; cl- s ptu •
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§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§4201(7).
(Intl ALL THREE of the following)
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
Tinstory personnel. H
2LI/We hereby affirm that instructions have been given to(funeral director name) giZ. kJ 2111-4)1:7-c
regarding the removal of any personal property or other thing o�f.'�4alue which any pe n signing below or any family
member of the deceased wishes to preserve. (aematoryname) *'ir/,t: 0k.J t17/'r77)P -'-/1 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
a cremation.
AtI/We hereby authorize(crematory name) .. 7a14-if/ "E �165 11Q d o t ti to cremate the
remains of the deceased.
FINAL DISPOSITION •• ,
The person uthorized to r ive the cremated remains of the deceased from the crematory is:
Name: �9 S L) �A%-c'��
Address: f,6 i.J f�r2/2' 'J $ &/` N/ Jo?,(fti J Phone: /cf- 7cf- 37V"
The cremated remains of deceased will be disposed of as follows:
gein.,2_,,c.;-e-X____ 46 ;4—A49-1'1.'4'9
If for any reasone person named above does not take possession of the cremated remains,
(crematory name) rIN=�:I5-w (2- 0--``-/-7 is authorized to give possession of the remains to
(funeral home name) 7t)/9.0I I i Joe- by delivery in person or by registered mail.
//4-•?.y ‘.i14NE- 3/97 S
DOS-1898-f-I (Rev.01/10) Name of Deceand Page 2 of 3
(Il:'- the following)
I/We understand that if the emains are not claimed within 120 days of cremation,
(crematory name) c/AIc01 i(w' C irk ib/21cJ1 may dispose of the remains in an irretrievable manner,
such as by scattering.
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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.
An urn pps not yet been purchased. I/We understand that if no urn is purchased or otherwise provided
(crematory name) jam' +t.1: �T j R.11.1.11 will place the cremated remains in a rigid temporary
container for delivery.
This Authorization Form was provid by(funeral dire ameJ 13 0J0ti;
was executed at(funeral home name) 7 ageoi a ff � t_
(funeral hameadd►ess) /.-� )i 12Q-EAi Srr N I /07 / 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,attests)to the accuracy and completeness of the information contained in this
Authorization Form and authorize(s)the foregoing.
Signed this ! 7 day of 11$ 20 / l3.
Typed for Printed Name
iynature �f y/
Addre13 i ' s. it 4e &l tie.cs I L." +"/' / U /
Typed or Printed Name Signature
•
Address
Typed or Printed Name Signature
Address
WITNESS:
e0C9?A i WADAhfC 1J 4 ‘ezOg
Funeral Director Typed or Printed Name Fun I Director Signature
& 3Ol
Registration Number
Hr\si S 11 .5
DOS-1898-f-I (Rev.01/10) Name of Deceased Page 3 of 3