Flewelling, Sharon A • TOrkl) OF QUEE.*'Brrit
PINE
VIEW CEMETERY AND
CREMATORIUM
QUAKER ROAD,
QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
m e S ar� Ftr�j/ ns*o
Case a 33S
Date of Cremation TULTime Z010
Cremation Started Q
p. l C
T =me Cremation Completed
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Type of Container 14100C1
H S (0
~emarks :
1 ' 3o
Authorization for Cremation and Disposition. NYS '
Dmsion 1
One Commerce Plaza,99 WashO,
Alban
(51tt,
www.dos.
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date: ),1 f 7 01 v k,
Number. �3.�
Crematory Name: P�/��v;�w ��
Address: G LA e.42-.4 y
i iv t 1 Aqa1 Phone: 7`ts---7`r77
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: ,cin tiro. /A, -FL w,,t R ,,, Marital Status: L as w A
Last Known Address: / V
5 ) (,_VCr rc,e� t�.ne 1 ccA • i Yo
i
Place of Death: Alt S : ) Albk7 j ( r
Sex: ❑M ®F Age:7 b � « (:OB: •• 3/z7/3 Date of Death: r 7 /o Estimated Weight)/l � g 1 S- l�
Description of casket/container in which remains will be delivered:
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.
o*
k I'I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law
section 4201 or a will containing directions for the disposition of his or her remains and (Continued next page)
St aio\ A. 1 l e wG it
DOS-1898 f I (Rev.01/10) Name of Deceased P91 of 3
1
s
ilni i. 4a.11owin•
i/We un rstand that if the remains are not claimed within 120 days of cremation,
7 (crematory name) , c ,,_c ,,,, �c....c�o,,'-•,� may dispose of the remains in an irretrievable
such as by scatt ring.
CREMATION CONTAINER/URN
1(1 • the following)
1 FM An urn to be used as a container for the cremated remains has been purchased from
fp r el s M o c -f. f4, ) . 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 provid by(funeral director nap 0I,L/T- �_a .�,,,r
S
was executed at (funeral home name) ei 5�.o .C_ f-- +4 '��
(funeral home address) J
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 uthorize(s)the foregoing.
Signed this 1-7 day of _ Ih 20
kk
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1 -`t-•il t-e,. L L. ,•‘„ -� � .cvr, w. .,//l
or Pnntgd Name gn u
-kt AT i 4L /` a (.Y...lelz-1.S J-Z" 1U i-�l si c Ar-
Address 1 _) /
Typed or Printed Name Signature
Address
Typed or Printed Name Signature
Address
WIT SS: _ •
,..7...bt.-c\-- I ._- '
Funeral Director Typed or Prinit- N ne a or Si
Registration Number
S11 Ct.(-7 N.. /---7-t."---Z,.....ei 1,
DOS-1898-f-I (Rev.01/10) Name of Deceased PasLe'3 2t 3
•
/ ,*
ire person(s) having priority under Public Health Law section 4201 and have the right to authorize
Ahe remains of the deceased. MylOur relationship to the deceased is as follows: ,
J
he list below)
f 3 Description: ..Kr v.� '& I
i .
1person designated in writing pursuant to Public Health•Law section 4201(3); •
.he surviving spouse;
The surviving domestic partner;
1. Any surviving child eighteen years of age or older;
:4. A surviving parent;
15. 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).
(It• illL THREE of the following)
- ,kt1 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
cr ry personnel.
e hereby affirm that instructions have been given to(funeral director name) Ro e r,t ,-)--• Gn ys,ti
regarding the removal of any personal property or other thing of lue which an person signing below or any family
member of the deceased wishes to preserve. (crematory name) i A C V:C-L„ c..„-}o r:",� is not
responsible for removal of personal items from the container or om 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
a mation.
IMIe herebyauthorize(crematory name) n `- V . . . �'^�^^`��� ' �^—
to cremate the
re ains of the deceased.
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name: R cr k ):
‹.: cancv't=.r ��CnyM, •c if•
Address: 7 of a m,.., Ave i. ) ]V Y r .. tag. Phone: 6 S`7-/A XY
The cremated remains of deceased will be disposed of as follows:
6 7 v,-.7., 1,0 (?1-e,,,,, ,c_ -t- H / _k,./---..._ ___k_.,,,,-,_A
192,,-/----(:)i ut..,e,„.,_6,,,.....L.„-
If for any reason e person named above does not take possession of the cremated remains,
(crematory name) ;✓\e u .c..- �e,...,,h-. r..,---, is authorized to give possession of the remains to
(funeral home name) ��4 S re,0 re-' �-. I.4� .�� by delivery
v inperson or by registered mail.
,cc r'-1 /4 . I r C,.. .
DOS-1898-f-1 (Rev.01/10) Name of Deceased age 2 of 3
•