Burgess, Frederick AOF
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�' CEMETER•Y AND 4 �../
QUAKER ROAD. ROAD, QUEFNSB NCREMATORIUM'
YORK 128N
(518) 745-4476 (518) 745-4-477
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Funeral Director
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Date of Cremation
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Authorization for Cremation and
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:3 70 (O
Crematory Name:
Number: (1 1, 2
Address:
Y Phone: 54 - 4 4 7q
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 mechanical)
designated container or um. Cremated remains generally Pulverized
Pulverized ed until lno single frieces and agment into a
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: 6,ejo,,ir.t,
Last Known Address:
Place of Death;
Sex: $All ❑F
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Age: -4 DOB _---d IW-/ Date of Death: oq/c� /Q
Description of casket/container in which remains will be delivered:
Person(s) in control of disposition, initial ONE of the following)
n rd am/ lAWaarP�_---
- - uGblynatea In a will of
Law section 4201.
know[
Marital Status: 4)i1we-J
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Estimated Weight: Mig
executed
sCcF'�n 4w� or a will corr[a n ng directions for the disposition of his orherremains and r(uo nt to Puebfi , _e alth Law
V �/� P 9 )
DOS-1898-f-I (Rev. 01/10) h!G EJ co -ems
Name of Deceased Page 1 of 3
I am/ we are the person(s) having priority under Pubi , r.� 2>I 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) rr rr
Number:: 3 Description: S C4-d1OQ
1. A person designated in writing pursuant to Public Health Law section 4201(3); 1
2. The surviving spouse;
2a. The surviving domestic partner;
3. Any surviving child eighteen years of age or older;
4. A surviving parent;
6. 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 islare 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(71,
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)
Me 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.
i� Me hereby affirm that instructions have been given to (funeral director name)
regarding the removal of any personal property or other thing of value which any person signing below or any family
member of the deceased wishes to preserve. (crematory name) i 'e— V, P ") oY,Q,I' A il! 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/We hereby authorize (crematory name)?l P14, V I W C ' Y,Q_M a k Y V to cremate the
remains of the deceased.
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from.the crematory is:
-,S�
Name: D 4& � ��//v' �w� 1,- Fuktv*'p I A�W—
Address: GO/ % 0 TI"e
The cremated remains of deceased will be disposed of as follows:
If for any reas!N"VaAj'4Af
e person naffed above does not toe possession of the cremated remains,
(crematory name) Y'011 is authorized to give possession of the remains to
(funeral home name) o itiv / 11i/ lw— by delivery in person or by registered mail.
DOS-18984--1 (Rev.01/1,0)
Name of Deceased Page 2 of 3
1
-Trait dldl the f g)
I/We understand that if the remains are not claimed within 120 days of cremation,
(crematory name) may dispose of the remains in an irretrievable manner,
such as by scattering.
CREMATION CONTAINERMRN
(Initial ONE of the following)
-12 An um to be used as a container for the cremated remains has been purchased from
�re.ec� l L. fit ILe Atoij . AI ikwA- and is described as follows:
Me understand that if the um is too small to hold the entire cremated remains, an additional rigid container may be
used for delivery.
-OR- d
An um has not yet been purchased. I/We understand that if rio um is purchased or otherwise provided
(crematory name) 6 _ V will place the cremated remains in a rigid temporary
container for delivery.
T, This Authorization Form was provided by (funeral direcprname) ,
was executed at (funeral home name) �,.,i �; - �vwCNw!�4-
(funeral home address) Jot � tuXI1k-7d and is signed by the funeral director
as witness to its execution.
Me 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,
�v
roved
day of 3
Typ or Printed Name
1OCD I o (11,0. NL
Typed or Printed Name
Address
WITN SS:
Fit era! birector Typed or Printed Name
l�lu-6s
Registration Number
DOS-18984--1 (Rev.01/10)
Signature
i
Signature
Name of Deceased Page 3 of 3