Dumphy, Peter R -
Tor1N of QUEEN,SBUWy
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director {n�
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Date of Cremation i1t,
Time Cremation Started h
Time Cremation Completed �:II ce1
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` Authorization for Cremation and Disposition NYS Department of State
I� 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: MZ ,C9/v Number: �O/Q 0/� 4 Z I(�
J
Crematory Name: k e U{ 41..ei776.e. I/ ' II
Address: 49t/ A a _ 0 Ote.G. ./4,57hc ./ // p.ef /Phone: 7 qv 4/97)
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 DECEASED
Name of Deceased: f7e 7e-- q i/� Marital Status:/Z7j4e_'
Last Known Address: y4,k �GA'2 -7 Jk/- 7 X ()%er 7 , / 7/J 2
Place of Death: o2� 6c,/-,err-7-7 l/1//--Gi , (1,4,6-� y/}_ 2
Sex: Ji91 OF Age: de DOB: 4_ ,cate of Death:i7/? Estimated Weight:/7 -
Description� of casket/container in which remains will be delivered:
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PERSON IN CONTROL OF DISPOSITION
(Person(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
pursuant 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 containingdirections for the disposition p on of his or her remains and ( ntinued next page)
A.ler- g J729/1
DOS-1898-f-1 (Rev.01/10) Name of Deceased Page 1 of 3
(Initial the following)
k ,I/Wr and rstand�that if the emains are not claimed within 120 days of cremation,
matory name / l/�Gf� c ,Or
//�f �� u/D,►'}%rh may dispose of the remains in an irretrievable manner,
such as by sca ering. •
CREMATION CONTAINER/URN
(I 1 ONE of the following)
I`� D An urn to be used as a contaiper for the cremated remains has been purchased from
I3ac7!yi 7c,a"i"�io 7>4 cc.///'.1-c 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-
An urn has not yet been purchased. I/We understand that if no urn is purchased or otherwise provided
(crematory name) will place the cremated remains in a rigid temporary
container for delivery.
This Authorization Form was provided by (funeral directo me)-4/17. t i- % `hio77 ,
was executed at (funeral home name o67- -�C `yo- .. 7. v77,c /Oy h ,
(funeral home address) 7/77h-P 7- G-- ,...e7 -�,ved.1 �/`I 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.
MilSigned this (� day of20 / d
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Typed or Printed Name Signature
Address e7C---t
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Typed or Printed Name Signature
•w
Address
Typed or Printed Name Signature
Address
WITNESS: _
dyes �� .C73//
Funeral Director(
irer oor((TTy�yped or Printed Name Funeral Director Signature
Registretion"N2 umber
b 7
V-,C:C.- X- c (1.27,j
DOS-1898-f-I (Rev.01/10) Name of Deceased v Page 3 of 3