Hollander, Blanche Alice I
TO T4'7 OF QUEEN,SBUICT
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
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Date of Cremation fj„ ), ,v, -- ')_ o iv
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- ' me Cremation Completed /.
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NYS Department of State
,,4uthorization for Cremation and Disposition Division of Cemeteries
one Commerce Plaza,99 Washington Avenue
Albany,NY 12231
(518)474-6226
www.dos.state.ny.us
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date:5/17/2010 Number:
Crematory Name:Pine View Crematory
Address:Quaker Road, Queensbury, NY 12804 Phone:518-745-4477
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
t,2! _ Yopeems =f h i pan 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
IDENTIFICATION T ION OF DECEASED
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PERSON IN CONTROL t I- DISPOSITION
(Person(s) ill control of rlispos/tir)n initial ONE rif the in/inviting)
pUrSU_r1t fr P1 I: iH,---alth I ..w: u:.nw
I/Vve 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 remains and lCnntin,,p4 nRxt node)
Blanche Alice Hollander
DOS-1898-f-I (Rev.01/10) Name of Deceased Page 1 of 3
L
Lam/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)
Number: 3 Description: 5+•-kgUrti/AA • C/-/i..47
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).
(Initial ALL THREE of the following)
re. / I/We hereby affirm that the body of the deceased does not contain a battery, battery pack, power cell,
ra ioactive 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.
.e ll,N I/We hereby affirm that instructions have been given to (funeral director name)Lance Evans
eurding the removal of any personal property or other thing of value which any person signing below or any family
___ -c ta_� deceased wishes
— - _ ::�c uc.a�ees�ia wishes to preserve. (crematory name)Pine View Crematory is not
rrp?wTt:e far removal of personal items from the container or from the remains of the deceased. Personal items
tpt:t i.i a.i ZZ C.wil:ii.
uvve iieteey stUCiIUiice (cremaror`j name), ���c ricv� viciiiCJiv.Y LU t 1eI!litiC tileael
ifi ti ilr iaGuuGGiE.
Ciki A i PksoneN@ITIPNI.i
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1 he person authorized to receive the cremated remains of the deceased from the crematory is:
DOS-18984-1 (Rev.01(10) ivdrr or e '4ei 'tea="'2 '
4 i .
•(Initial the following)
__ - I/We understand that if the remains are not claimed within 120 days of cremation,
( matoryname)Pine View Crematory 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-
_i — An urn has not yet been purchased. I/We understand that if no urn is purchased or otherwise provided
. (crematory name) Pine View Crematory will place the cremated remains in a rigid temporary
container for delivery.
This Authorization Form was provided by (funeral director name)Lance Evans ,
was executed at(funemlhomename)Miller Funeral Home ,
(funeral home address)35 West Main St., Indian Lake, NY 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 17 day of May , 20 10
Joan Hollander .>< G-grrit t /f,�� /
Typed or Printed Name Signatu
Address
Typed or Printed Name Signature
Address
Typed or Printed Name Signature
Address
WITNESS:
Lance Evans
Funeral Director Typed or Printed Name Funeral Director Signature
01109
Registration Number
Blanche Alice Hollander
DOS-1898-f-I (Rev.01/10) Name of Deceased Page 3 of 3