Radcliff, Theadis • TOTIN
OF QUEESV3Z1 .yPINE VIEW CEMETERYA
QUAKER ROAD, CREMATORIUM
QUEENSBURY, NEW YORK 12804
(518) 745-447.6 (518) 745-4477
Funeral Director
N'a,me I or ah
evtu s � � .
Case N Z�
Date of Cremation Tut.
Time Cremation Startedv
Kb
T =me Cremation Completed
ID: h s
Type of Container
"emark5 : `' ` rS
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hrY8 parartmant of State
'Authorization for Cremation and Disposition Division of cemeteries
on Carfrtneroe Prn2R.@0 Washington Avenue
Afbony,NY 12231
(518)474$22g
T
mww.Qos.atete.ny.us
This Authorization Form roust be completed and signed prior to delivery of remains for cremation.
Date: 7 !Al / I Number all) - 44 3 .) .
Crematory Name: /47 e. 140 efelti7Or '
Address: dace lily /05d ,Phone: //) 7415"�—941 ,v
CREMATION IS AN IRREVERSIBLE AND PINAL 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 ail 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. Oremated remains generally are pulverized until no single fragment is
recognizable as skeletal tissue.
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.
ENTIFJCATION OEJ C SED•
•_____7_ d__
Name of Deceased: �+� ���:�. Marital Status�� p�!'��
Last Known Address: //IC 9 { he c Ay left t f
Place of Death: gr6:04.___11 dZdaj 2rrn /ir VCie -
Sex: EM 7F Age: I .cDCB: cam/?/� Date of Death: 7 /e /O Estimated Weight: 1/
Description of caSket/eontaner in which remains will be delivered:
--/-/-7.--Zald_e lid
* P .11_59N,1. CONTROLO_F DISI OS LQN frle- •
(Person(s)in aontmi of dlacos1loa,MN ONE of the fodowing)
lam/We are the designated agent of the deceased designated in a will or written instrument executed
pursuant to Public Health Law section 4201. •
-OR-
71--- e have no knowledge that the deceased executed a mitten instrument pursuant to Public Health Law
1/W
9section 4201 or a will containing directions for the disposition of his or her remains and (continued next page]
72502(AS •PeLfl -
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I anal we are the penson(s)having priority under Public Health Law section 4201 and have the right to authorize
cremation of the remains of the deceased. My/Our rel
ationship p to the deceased is at follows:
(Insert from the list below)
Number: Description: A -
1.A person designated In writing pursuant.to Public Health Law section 4201(3);
2.The surviving spouse;
2a.The suviving demestic partner;
3.Any surviving child eighteen years of age or older,
4.A surviving parent;
S.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 Sunogate'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),
r. - •LI. THREE of the following)
1We hereby affirm that the body of the deceased does not contain a battery, battery pack, power call,,
is
r-•iaactive implant,or radlcctive 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.
/41 it-
- hereby affirm that instructions have been given to(amoral c r name) Je d
.=garding the removal of any personal property or other thing o slue ich a person egfling below or any family
member of the deceased wishes to preserve. (crematory name)1 Y/�tr� (ice!' �' i� 7C._ 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.
hereby authorize try na/* 4e., / C'1 to cremate the
rr�ns of the deceased.
E P 2C l.AQIt
The person authorised to receive t cremated remains of the deceased from the crematory is:
Name: C. •a..2 _ ..
Address: /€Rc ($ / I�/41G • R o9/ Phone 1 )t 4'5l/r
The cremated remains of messed will be disposed of as follows:
rrAtifed /-0 jairkoL 4.de I/5 e ISR toier all
If for any reason ttte person named above does not take possession of the cremated remains,
tc,.emetorynRm ) # 9(eeD ('r iletA fl ;is authorized to give possession of the remains to
eimmommoneme �, Cry-!)`' ti /�/11 L/r7G�17 by delivery in person or by registered mail.
COS.1898-f4 (Ref..01/10) • Name of Daceeserf '` Per 2 of 3
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► ,ii (the following)
IMte un nd t t if he mains are not claimed within 120 days of cremation,
(crematory name) • ) d- "irl „ may dispose of the remains in an irretrievable manner,
such as by scattering.
" @I 7'Ca QNT'. IMEW!LK
anal,ONE of the Wowing)
An urn to be used as acorttainer for the cremated remains has been purchased from
and is described as follows:
I/We understand that if the urn Is too srnall to hold the entire cremated remains,an additional rigid container may be
used for delivery,
-OR-
n um s nOt',Y�been nchased. HWe understand that if no urn is purchased or otherwise provided
acorrnnr►re) . 1/') YieGc) (2, i• will place the cremated remains in a rigid temporary
container for delivery.
This Authorization Form was pro by(Amami rt ) fileJt#',rl c i
was executed at e) C C1"e�J A C... •
(loners:ttome address) r and ' sig
l Ined by the funeral director
as witness to its execution. ,b'{ /ir
UWe have received a completed copy of this Authorization Form,
The person(a)identified below Ware 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 .i(Plm
Authorization Form and authorize(s)the foregoing.
Signed this day of _t_ 0 {O
!-ry E1 Floc:.l; •
k 'Wed orName 5rq
ia-
AoCireas
typed or Prirdod N e Signature
Address
-4`� TERESA M.MUELL ER
t� J 1 1 OYl 1r v Nota y Public,State of N.Y.
'hi .r'.0 Ort.A-
Nq 01MU5023717
T orF nfed Nacre !♦ gnafure Commission Exp.Feb,i4,2
Address
WITNESS:
runeref c*e for typed or Printed Name r` Wist
c>�e
Rol:fart/Pen Number
ilephs /rade./te#___,
Dos-189841 (Rev.01/10) Nuj
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