Palmer, Benjamin Landon . TO`MN 0 QUEE (ZIZT
PLNE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY NEW YORK 12804
(518) 745-4476 (518) 745-4477
F neral Director_���Sp�
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Case # 'Z
Date of Cremation PI 700
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i uthorization for Cremation,and Disposition . NYS Department of State
/`' Division of Cemeteries
• i , 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: MR)/ /D c0O/O Number: Z Z 1
Crematory Name:6'/A/ k--Gd C R.E7n 13To oq/Gl ty) .
Address: 4)c/FEi/S Qg u# Ny, /42 d'O5dr Phone: 7 5— r 77
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 .
Me 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
;onductedbefore a witness and will be done in privacy, with dignity and respect.
DENTIFICATION OF DECEASED
Name of Deceased: 9L'sA/aNin A/ 1, /DD1 scPigxtrzER Marital Status:(S')
Last Known Address: 2 , 12701R6.4 ,4r4/}-A/g CO)z'sv7-0CA Sly, /pdgo/
Place of Death: „Pithy G M2 °vE •
Sex: E4M OF Age: /G DOB: 9/, }//?5S Date of Death:. ///�D/O Estimated Weight: / "O/4s
Description of casket/container in which remains will be delivered:
NQv oWas1 110 CRAW/An0W suP0°A,CO.
DEL LI X� CREmq-77a.�/7 R. Good a/aideD COrr7eas/TE/C4A'O Cep foeo 7o e
'ERSON IN CONTROL OF DISPOSITION
e n(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
lursuant to Public Health Law section 4201.
OR-
I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law
ection 4201 or a will containing directions for the disposition of his or her remains and (Continued next page)
6EN379mi 1V .�. C'e '4 /77 7
OS-1898-f-1 (Rev.01/10) Name of Deceased Page 1 of 3
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I am/we are the person(s) having pri9rity 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. T. description: / p '#�� •
`
1.A person designated in writing pursuant to Public Health Law section 4201(3);
2. The surviving spouse;
2a. The surviving domestic partner; . •
3.An 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).
, al
(Initial� ALL THREE of the following)
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l 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.
3 c I/We hereby affirm that instructions have been given to (funeral director name)9tot;/C9/c/27, SO 1/
regarding the removal of any personal property fir other thing offvalue which any person signing,below or any family
member of the deceased wishes to preserve. (crematory name)6�//,(�!�14 0P/ C 77/-17Z>R/U/7'' 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.
' I Vf� ♦ •�
WVe hereby authorize_(crematoryname)(59/A/�///� �QQQ7M70R/Uri to cremate the
remains of the deceased. •+
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name: r C/CF A'. 1?2/9
Address:6'0 77 roes? T g),,m/ my, i,,Q0P- 7
The cremated remains of deceased will be disposed of as follows:
f
�C 774R/✓g D '77, F i1/19,
If for any reason the person named above does not take possession of the cremated remains,
(crematory name)9/Alb' eaejedOn1/97" /Gf/Y1 is authorized to give possession of the remains to
(funeral home name)/Th 9 CA/ Fa110Rf4L /ft?>77 r by delivery in person or by registered mail.
DOS-1898-f-1 (Rev.01/10) Name of Deceased Page 2 of 3
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(1 iti the following)
I/We understand that if the remains are not plaimed within 120 days of cremation,
(crematory name)e9/Nr6///f) CR8772 17blie/I/AI may dispose of the remains in.an irretrievable manner,
such as by scattering. - - .
CREMATION CONTAINER/URN
0.6210NE of the following)
An urn to be used as a container for the cremated remains has been purchased from
A//A 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-
P
An urn has not yet been purchased. I/We understand that if no urn is purchased or otherwise provided
(crematoryname)re/A/5///$JCRI:771nrezS/ will place the cremated remains in a rigid temporary
container for delivery.
This Authorization Form was provided by (funeraldirectorname)aiReIGLC,, /1'. E&'/72Oo /�
was executed at (funeral home name)rASO PL//i�&?' /L Herir/
(funeral home address)(PeX 77 OtR714 t/h/ Ny /o? 1.7 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 / ' d y of 20�D .
Ci , R44= 09-A /./ cPi91 h1'2
Typed or Printed Name Signature.
cox /60. F oRr E3-AtAi Ny, /_20P-?7
Address
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Typed or Printed Name Signature
Address •
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Typed or Printed Name Signature
•
Address
WITNESS:A
W
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/ cg K. Ma sdis( Funeral Director Signature
Funeral Director Typed or Printed Name
Registration Number
£ 1h`19 n )N , 609 171g_/2
DOS-1898-f-I (Rev.01!10)
Name of Deceased Page 3 of 3