Champagne, Luva A L O`{' v OF QUEENSIBURT
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
l /I Funeral Director S•,n i6 `
Name G u J y (,F;,r
�� Case # Z4I
Date of Cremations 3 ZOf(
Time Cremation Started
Time Cremation Completed_ '
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Type of Container Vood (w .pw/r De
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Authorization for Cremation,and Disposition . NYS Department of state
< 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: Olyi-vS 2:1 LL ' Number r
Crematory Name: IJ `I�i \)\ ? CkcLo-yr-i--(5
Address: a11� Yam, Q k), ( ( ',''0
CREMATION IS AN IRREVERSIBLE AND FINA � Phone: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.
PENING OF CONTAINER .
le crematory may only open the container holding the un-cremated human remains in limited circumstances, such
>to.confirm the identity of the deceased or to ensure That no material is enclosed which might injure employees or
image crematory property. If human remains are delivered In a container which is not suitable for cremation
ich as a ceremonial or rental casket,the crematory will require that the remains be moved into a suitable
rntainer before it accepts the remains. The opening of a container or the transfer or removal of remains will be
Inducted before a witness and will be done.in•privacy, with dignity and respect.
•
ENTIFICATION OF DECEASED `
ame of Deceased: � J c� .-=� �,__,\ ri\` � Marital Status:
1st Known Address: N CQSwN 4-_ 6- , (--t�,� 4k, ql
( 2b'
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ace of Death: C) {'1 S qcja,), .) .
w: ❑M XF Age:C\.Q DOB: 13 t '3\
`L* Date of Death:Lc \ Estimated Weight .
,scription of casket/container in which remains will be delivered:
Milk\t"" Ei- CA \--_ ,VA-r)
- U.Ar,,,rc , • .
RSON IN CONTROL OF DISPOSITION
rson(s)in control of disposition, initial ONE of the following)
am/We are the designated agent of the deceased designated in a will or written instrument executed
ant Public Health Law section 4201.
•
I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law
tion 4201 or a will containing directions for the disposition of his or her remains and (Continued next page)
tW c. Lhci4YVCAV--
-1898-1-1 (Rev.01/10) Name of Deceased Page 1 of 3
.
I am/we are the person(s) having prigrity 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: / !.,v ,
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)
‘.---6C 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
Auorization Form. Failure to remove these items prior to cremation may result In harm to the crematory and
crematory personnel. ,
- ..EL bAI/We hereby affirm that instructions have been givento (funeral director name) 11
U-�'C ,
r garding the removal of any personal property or other thing gf-yalue which any person signhig below or any family
member of the deceased wishes to preserve. (crematory name) V IN J ii +..,-' 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. 0 •
2,_.c..d_
I/We hereby authorize (cremaroryname) I�v (. to cremate the
r mains of the deceased. •N ,
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name: 63 .1-\ 'LO, e_).%el.U/A— i-kkil_ CI—
Address: �01 KO ( k) ' Phone:
i
The cremated remains of deceased will be dis ose f as follows:
,,....:3 ,
0,, Vi\VS 59 0—\(k_k_.' 1 '
C k_' )/V\
If for any reason the person named above does not take possession of the cremated remains,
(crematory name) t l t Q J&u is authorized to give possession of the remains to
(funeral home name) --)'.r\Vtd L�- P c. J by delivery in person or by registered mail.
--,--S:OW- C.44Y\06\14,k
DOS-1898-f-I (Rev.01/10) Name of Deceased Page 2 of 3
(Initial the following) 1
!` FG liWe andpil\t
tand that-if the remains are not claimed within 120 days of cremation,
c matoryname) I cIA) may dispose of the remains in.an irretrievable manner,
ch as by scattering. •
CREMATION CONTAINER/URN
(Initia(ONE of the following)
�E1 i✓An urn be used a a container for the cremated remains has been purchased from
1 3111� {,#t,!1 }( r 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 provi ed by(funeral director n me) .-k— CL -A td;L QkJ '
was executed at (funeral hom name). I. '1! - L... '
(funeral home address) 40 ! 4� a l lc l 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.
Steed this a() day of , 20
O 1 C_A--\c C, '-? - 9-cz--y ���
T n d or Printed Name U , s Qom
in ure. a
Address
Typed or Printed Name Signature
Address •
Typed or Printed Name Signature
Address
WITNESS: � - ���` j\
tv�``1, d Funeral Director Signature
Funeral Director ped or Printed Name
Registration Number
LOB Cw
• � 111 tL.
DOS-1898-f4 (Rev.01/10) Name of Deceased Page 3 of 3