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. uchorization for Cremation and Dis osition . NYS Department of State
Division of Cemeteries
1 One Commerce Plaza, 99 Washington Avenue
Albany, NY 1223.1
(518) 474-6226
www.dos.state.ny.us
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date: Number: 7 45
Crematory Name:
Address:
T%.3y Phone: 7 95 J9Z.2
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
c' 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 femains. 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: r Marital Status:
Last Known Address:
Place of Death: �'-,� s ls= )� "Y
Sex: ❑M� Age: �Z DOB: ) ))j� 137 Date of Death: ,5r 3) )o Estimated Weight: j7�
Description of casket/container in which remains will be delivered:
PERSON IN CONTROL OF DISPOSITION
(Person(s) in control of disposition, 'ni i 1 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:
-OR-
I/W o nowle e that the deceased executed a written instrument pursuant to Public Health Law
secti n 4,' wl o t it ing irectio�f r the disposition of his or her remains and (continued next page)
DOS-1898- - /10) Name of Deceased Page 1 of 3
Wv
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: A"
(Insert from the list below) AC,"
_f
Number: Description:
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 oMe eased and who has executed a written statement
pursuant to Public Health Law §4201
(initial ALL THREE of the following)
I/We hereby affirm that the bo th ceased does not contain a battery, battery pack, power cell,
radioactive implant, or radioactive device and t ny s ch ma rials were removed prior to the execution of this
Authorization Form. Failure to remove ' pri r t mation may result in harm to the crematory and
crematory personnel.
I/We hereby affirm that 1 stru a b given (funeratdirectorname) YY)
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. ( name) �;yt t� Ir �-r ,x,o.�„ is not
responsible for removal of personal items fro the nt 'ner or m the remains of the deceased. )Personal items
left in the container or with the remain stro ed the cremation process and cannot be retrieved
after cremation.
951�7/7 I/We hereby authorize (crematory
remains of the deceased.
FINAL DISPOSITION
.,
The person authorized to receive the cremated remains of the deceased from the crematory.is ,
Name: Ui
Address: Qk e �,
The cremated remains of
be disposed of as follows:
to cremate the
Phone: --� 9-:�> - ) )
If for any reason the person named above does. lot take possession of the cremated remains,
(crematory name) p; 'Vi cw is authorized to give possession of the remains to
(funeral home name) by delivery in person or by registered mail.
q ) ) ca
DOS-1898-f-1 (Rev. 01/10) Name of Deceased Page 2 of 3
i
(in itial fhe following) XA .21,
-e understand that if the remains are not claimed within 120 days of cremation,
(c&matoryname) �IY1z )/, C,� may dispose of the remains in an irretrievable manner,
such as by scattering.
CREMATION CONTAINER/URN
(Initial ONE of the following)
An um to be used as a container for the cremated remains has been purchased from
and is described as follows:
I/We understand that if 6e um is too s all to hold the entire cremated remains, an additional rigid container may be
used for delivery. — (i i o
-OR- X°'�
An um has et b \ �urch;ase a understand that if no um is purchased or otherwise provided
(crematory name) , d-,)- V ) will place the cremated remains in a rigid temporary
container for delivery.
This Authorization Form was provided by (funeral director name) m1n.-.- )�' J . .T,a ,
was executed at (funeral home name)
(funeral home address) r 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 islare 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 day of c , 20 )o
X C5 1lei2i �T
Typed or Printed Name Signature
WITNESS:
Mrk t-&� 51 �0 1
Funeral Director Typed or Printed Name Funeral
as 2e2J
Registration Number
DOS-1898-f-I (Rev.01/10)
7{ ecr-'1.0 -)�- ! 1ST��'
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Name of D sed Page 3 of 3
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