Hungerford, Gerald J,t
OT QUEE9�,-51BPINEVIEWCEM l"1.�' �J
WAXER ROAD ETERY AND CREMATORIUM
QUEENSBURy, NEW PORK 12804
(518) 745-4�476 (518) 745-4.477
t Funeral Director
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Time Cremation Started
Time Cremation Completed
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Authorization for Cremation and Disposition NYS Department of State
f' 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: c% "3 s 9 D/ C) Number: V 1
Crematory Name: )I U
Address: C �
Phone:
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
d age crematory property. If human remains are delivered in a container which is not suitable for cremation
s�_a 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 Jn. privacy, with dignity and respect.
Name of Deceased:
e-rw V , Uxr
Last Known Address: 4 010
Place of Death: C-:cCcAoN., Ryy
k1i
[b
Marital Status:
-_ J
Sex: -I—M OF Age: %_ DOB: g art I 33 Date of Death: tjio Estimated Weight:
Am.
of casketteontainer in which remains will be delivered:
Cc'r ryi c rj
PERSON iN CONTROL OF DISPOSITION
(Person(s) in control of disposition, ' i lal 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.
a �
T7 1 � e 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 pag
1\� Ge-rcM g4-,-ni' 4- A J
DOS-1898-f-I (Rev. 01/10) Name of Deceased Page 1 of 3
I am/ we are the person(s) having priority 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 te list below)
Number: c Description:
1 A person designated in writing pursuant to Public Health. Law section 4201(3); ,
Vhe surviving spouse;
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 REE of the following)
I e hereby affirm that the body of the deceased does not contain a battery, battery pack, power cell,
radioactiv implant, or radioactive device and that any such materials were removed prior to the execution of this
uth tion Form. Failure to remove these items prior to cremation may result in harm to the crematory and
I y e hereby affirm that instructions have been given to (funeral director name) Ala
regarding regarding e removal of any personal property or other thing f value which any person s ing below or any family
\ ' Y
fimember the deceased wishes to preserve. (crematory name) lrz.V �0 is not
resporieible for removal of personal items from the container or from the remains of the deceased. Personal items
I -i—n-thlecontainer or with the remains will be destroyed by the cremation process and cannot be retrieved
after crema on.
e hereby authorize (crematory name)P,,-�J,�-,j to cremate the
(remains o e deceased.
'FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name* r.a1p \?)\�ti
Address:
The cremated remains of deceased wine disposed of as follows:
Phone:
If for any re the person named above does not take possession of the cremated remains,
(crematoryname),�J1 �JV is authorized to give possession of the remains to
(funeral home name) by delivery in person or by registered mail.
DOS-1898-f-1 (Rev.01/10)
Cs�a-Q� � n � 4�
Name of Deceased Page 2 of 3
(lam in _ l?the fo /0M.r�g)
IA� and stand t at if the remains are not claimed within 120 days of cremation,
(crematory na m) 1� k, �9� may dispose of the remains in an irretrievable manner,
such as by scattemng.
(Initial ONE the following)
An to be u e as a container for the cremated remains has been purchased from
and is described as follows:
—�`
iA rye r
I/We understand that if the um is too small to hold the entire cremated remains, an additional rigid container may be
used for delivery.
-OR-
An um has not yet been purchased. Me 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 d by (funeraalldirector name) ` �r J�'t `-'& ,
was executed at ( era/ home name) 2 �' > �^ lJ
(funeral home address) and is signed by
as witness to its executi .
Me have received a completed copy of this Authorization Form.
the funeral director
The person(s) identified below is/are 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
Authorization Form ad authorize(s) the foregoing.
�Nned this .� day of ^ 20 10 n n
or
Address
Typed or Printed Name
Typed or Printed Name
Address
WITNESS:
Funeral Director T or Printed Name
Registration lVumber
DOS-1898-f-I (Rev.01110)
Signature
Signature
cl)�QAGU
Name of Deceased Page 3 of 3