Loading...
Trombley, Clarie M • TOWN OFQUEE9Q'BU.k9/"'• PLNE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director ame 10 Case Date of Cremation . ` me Cremation Started ', 1 0 fa ' lme Cremation Completed 1 ©o rCld- e o f Container C r` Qr C A a '' k 5 �y' Art r ��'• � J IQ Are • Auti7orizafion for Cremation.and Disposition . NYS Department ofState . ) 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: Z�7 25)I Number: Crematory Name: Pi . Address: ( ��✓ vK_ioJ `^ t 'y Phone: ' 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 reqyired 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. DPENING 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 iamage crematory property. If human remains are delivered In a container which is not suitable for cremation :uch as a ceremonial or rental casket, the crematory will require that the remains be moved into a suitable :ontainer before it accepts the remains. The opening of a container or the transfer or removal of remains will be :onducted before a witness and will be done in-privacy, with dignity and respect. DENTIFICATION OF DECEASED game of Deceased: C C`1 r` I nom b`( .-41 /Marital Status: I , _ast Known Address: • 'lace of Death: C5rc )4. .,Q G . G in/ ;ex: ❑M F Age: r] DOB: 0 J9 I � 1 ( 3Y Date of Death. 5/1 )I j p Estimated Weight. )escription of casket/container in which remains will be delivered: • ERSON IN CONTROL OF DISPOSITION erson(s)in control of disposition, initial ONE of the following) I am/We are the designated agent of the deceased designated in a will or written instrument executed irsuant to Public Health Law section 4201. _7-- tileVe have no knowledge that the deceased executed a written instrument pursuant to Public Health Law ction 420'� or a will containing directions for the disposition of his or her remains and (Continued next page) / n , S-189841 (Rev.01/10) Name of Deceased Page 1 of 3 - I amlvve are the person(s) having pri?rity 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). 1 ' Number. Description: T�.'.1-I .0 1.A person designated in writing pursuant to Public Health Law section 4201(3); 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 thedeceased and who has executed a written statement pursuant to Public Health Law§4201(7). (1Ritia(ALL THREE of the following) I/We hereby affirm that the body of the deceased does not contain a battery, battery pack, power cell, raoactive 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 rmatory personnel. 1 (^ • ti W rI /,� I/We hereby affirm that instructions have been•given to(funeral director name) Pn \`� re arding the removal of any personal property or other thing 6f�al hich(ny person signing below or any family member of the deceased wishes to preserve. (crematory name) I t--t_ 4(--VJ 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. ` `- \r��` to cremate the I/We hereby authorize (cn:maroryname) re ains of the deceased. •• FINAL DISPOSITION The per n authorized to receive the cremated remains of the deceased from the crematory is: Na me: `�0,-N- Wc,..\-\. Address:LP1 (-2-- 1 __) Phone: • The cremated remains of deceased 1 will be disposed of a follows: (--?,.e._____ _Nk_, „ 1.., -\)c.v-c,‘ 'A If for any r the Recson named above does not take possession of the cremated remains, (crematory name \` is authorized to give possession of the remains to (funeral home nameVr1 L\') by delivery in person or by registered mail. C.,\CO4 \k -A v fit DOS 1898-f-I (Rev.01/10) Name of Deceased Page 2 of 3 (ligtfa4 .•the following) ' - _. ttWe tm erst nfl that if the remains are not claimed within 120 days of cremation, (cremfatoryname) jigs-t V,�t.' 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. . - R' (i '-' n urn has not yet been purchased. I/We understand that if no urn is purchased or otherwise provided \ (crernatoryna,e) will place the cremated remains in a rigid temporary '"container f r delivery. This Authorization Form was provided by(funeral director name) was executed at (funeral home name) (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, attests)to the accuracy and completeness of the information contained in this Authorization Form and authorize(s)the foregoing. Signed this , ,'Cl day of Typed or Printed Name Signature. Address • Typed or Printed Name Signature Address • Typed or Printed Name Signature Address WITNESS: r W,2_,(�C_\ O\-1- v . Funeral Director TyAed or Printed Name Funeral Director Signature Registration Number • C_Ac-v-c__ \ )\ Vc `c \()\-(-'\ DOS-1898-f-I (Rev.01/10) Name of Deceased \Page 3 of 3