Gavin, Dianne M,c
OT
PWE vIE QUEE9�50U
�' CEMETEE Y
QUAKER ROAD, QUEFJ`1S8 ANC CREMATORrUM
URY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Director
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I q .1 � Klun8r8,
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Case # 1110
Date of Cremation
Time Cremation l� ZG U
Started
Time Cremation Completed
TYDe of Container B
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remarks.
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Authorization for Cremation ;and Disposition r.t : NYS Department of State
Division of cemeteries
One Commerce Plaza, 99 Washington Avenue
Albany, NY 12231
` (518) 47"M
www.dos.state.ny.us
This Authorization Form must be completed and sigped prior to delivery of remains for cremation.
Date: �� �o . 01 z, Number:
Crematory Name: 4)& e v ; e_, Cre/ki-Ac 3t
Address:_ Q11-L k6l, L-k
QY i'axb4(
Phone: -b- = "77
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 tak��easonable efforts to remove all.of the re_ mains.and other material from
the cremation chamber,` but'some minimal'dust ana'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
realns"gerierally 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,th t,no material.is,enclosed which might injure employees or
damage crematory property; if human remains a're delivered in a container which is not suitable for cremation
such as a ceremonial oriental caskei, 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: C)i ; c, A,n'L A I
�V
Marital Status: M 4 Pf. X
Last Known Address: `� C L ; �� �� , ��� D16
Place of Death:
Sex: ❑M XF Age:'+I DOB: •- a/3 / i� 1 Date of Death: %Z 7 /o Estimated Weight: �0 /�S-
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.
fv 6 I/We have no knowledge that the `deceased executed a written instrument ur t t P
section 4201 or a will containing directions for the -disposition of his or her remains and (Continued nexticageealth Law
( P9)
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 r
cremation of the remains of the deceased. My/Our relationship to the deceased is as follows:
(Insert from the list below) ' -
Number:
of Dgscription: �P V : V ,e,
1. A person designated in writing pursuant t ubli 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; I '
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 imina public adistrator. appointed pursuant to the Surrogate's Court
Procedure Act; 't
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)
w 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 item§ prior to. cremation may result in harm to the crematory and
crematory personnel. �t
IM/e hereby affirm that instructions have been given to (funbraliirrectoi An niej ' �vg'er � _ >✓ns�w oPe_.
regarding the removal of any personal property or other thing of lue which any person signing below or any family
member of the deceased wishes to preserve. (crematuyname) f ne--V : e -1. is not
responsible for removal of personal items from the container or from the remains of the deceased. Personal items
left in•the contalper.or. with the remains will be destroyed by the cremation process and cannot be retrieved
after cremation.
W G I/We hereby authorize (cramC._(`6
atory name) V ; ,�a'�; ,,,,� to cremate the
remains of the deceased.
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name: Rre , �wsmarc��rzL 44a.,e.; �_
Address: -] Al Co r`� �j I aq L Phone:iaSS—
i
The cremated remains of deceased will be disposed of as follows:
C.-r-r X .A- 574, /tA c-�- r
f�
If for any reasorhhe person named above doeV not take possession of the cremated remains,
(crematory name) ' n V ; 1✓t-3 is authorized to give possession of the remains to
(funeral home name) ,�„� A.M. o by delivery in person or by registered mail.
DOS-189&N (Rev.01/10)
lu^�� A-
Name of Deceased Page 2 of 3
s j_hrdUal the following)
J
0a"6Me and stand that if the remains are not claimed within 120 days of cremation,
(crematory name) K, A e-v; w may dispose of the remains in an irretrievable manner,
such as by scatte ' g.
ffad al ONE of the following)
L-) G _ An um to -be used as a container for the cremated remains has been purchased from
'41-�5'%0rC_ T, P_r'_ 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-
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 providy (funeral directorngcae)- oSe4,4—_
was executed at (funeral home name) _ fCnA sAcZ>rc ! Lk cr c..
(funeral home address)—Z Sher- .4vi e <,/ *" g 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 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 . 20
Typed or Printed /+ / Name Signature x ' v — � -
Address
Typed or Printed Name Signature
Typed or Printed Name
WITNESS:
Funeral Director Typed or Printed Name
bC-1 !I1(0
Registration Number
DOS-1898-f-I (Rev.01/10)
Signature
Name of Deceased Page 3 of 3