Bartholomew, Angelinei
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, QUEE9�,-PINEV"EWCEMERY ��
QUAKER ROAD, UEAND CREMATORIUM'
QUEENSBi1RY� NEW YORK 12804
(518) 745-4476 (518) 745-4.477
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Funeral Director w
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Case # Cfl�
Cate of Cremation
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Cremation Started
Time Cremation
Completed
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Type Of Container /, I�r�`M,�a
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20
NYS Department of State
Authorization for Cremation and Disposition Division of cemeteries
r- One Commerce Plaza, 99 Washington Avenue
Albany, NY 12231
(518) 474-6226
r� www.dos.state.ny.us
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date: S p i. l o, Z.Q 10 Number: vl 1
Crematory Name: Pine View Crematorium
Address: Quaker -Road, Queensbury, NY Phone: 745-4477
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 um. 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 R
Name of Deceased: A h Go- t r) R- �3x r'--h o I o m e t,J
Last Known Address:
Place of Death:
�o rr*" T
Marital Status: VJ
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Sex: ❑ M Age: 9 C) DOB: • (3 Date of Death: / d Estimated Weight: / 3 d 16.
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 sectionA20.1.,
-OR-
�p �b 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)
�a .. me n .e�` ✓>, e. ��Imo/
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DOS-1898-f-I (Rev. din b) " a '� a Name of DYeasd 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 the list below)
Number: Description: V
Y
1. A person designated in writing pursuant to Public Health Law section 4201(3);
2. The surviving spouse; F, .)
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 Surrogates Court
Procedure Act; - �T
10a. Any other persort.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)
_ IMe 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.
IfWe hereby affirm that instructions have been given to (funeral director name) 2Q ne eln 1�7-
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) Pto-e— ?cam , Cr-�1,na -kr a is not
responsible for removal of personal items from the container or from the remains of thel deceased. Personal items
left in the container or with the remains will be destroyed -by thecremation prose§s bird ca(nriot, be retrieved
after cremation
UVlle hereby authorize (crematory name) ` f I n e Y j Q (� �m c' +D C to..cremate the
r r_emains of the deceased. '
f
Fkt 'L`DI$POSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name: r- .Carleton_ Funeral, Home., -.Inc,,.
? - n a • 6
Address" 68 Main Street, Hudson Falls, NY 12839 Phone: 747-4243
The cremated remains of deceased will be disposed of as follows:
q
~ ba-c l- + jr4-j- 21nz� tom R -
If for avy reason the person named above does not take possession of the cremated remains,
(crematoryname) Pine View Crematorium is authorized to give possession of the remains to
(funeral home name) Carleton Funeral Home, Inc. by delivery in person or by registered mail. \J
1, t, n4e— ea,4-ko
DOS-1898-f-I (Rev. 01/10) Name of 691eased Page 2 of 3
-y(Mitlal ttheefollowing)
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I/We understand that if the remains are not claimed within 120 days of cremation,
(crematorynarAe) Pine View Crematorium may dispose of the remains in an irretrievable manner,.
such as by scattering.
CREMATION CONTAINERIURN
(Initial ONE of the following)
j0 5-B- An um to be used as a conAiner for the cremated remains has been purchased from
(e met toe-- and is described as follows:
S 'hee, d— j Lr in _
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. I/We understand that if no urn is purchased or otherwise provided
(crematory name) Pine View rremai:nri lam will place the cremated remains in a rigid temporary
container for delivery.
This Authorization Form was provided by (funeraldirectorname) Do n?e/1
was executed at (funeral home name) C'a rl Pf.on Funeral Hnme Inc.'
(funeral home address) _6g Main Street, Rudson Falls NY 12839 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 authorize(s) the foregoing.
Signed this day of se
Su. s at, h (l3 ,Q,2o C'-"A .
Typed or Printed Name
3 3 —rA 4-s 14w
Address
Typed or Printed Name
Address
Typed or Printed Name
Address,
WITNESS:
"077 V1-k'q-C-
Funeral Director Typed or Printed Name
_67�) a aL 7v
Registration Number
DOS-1898-f-I (Rev.01/10)
Signature
Signature
10
Name f Deceased Page 3 of 3