Rosenbrock, Donald E,_/ TIN OT QUEE9�,-5BPINEVIEW CEM '�.J
QUA-K.ER ROAD, ETERY AND CREMATORTUM�
QUEENSBY NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
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Case # Liz
Date of Cremation
Time Cremation 3 ZOI()
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Time Cremation Completed
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NYS Department of State
a Authorization for Cremation and Disposition 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 sigped prior to delivery of remains for cremation.
Date: �, ao)o Number:
CrematoryName:
Address:
/ 6'I Phone: �� y��f l a
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS. v
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 seasonable efforts to remove all of the re_ mains -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 a're delivered in a container which is not suitable for cremation
such as a ceremonial or rental casket, the Icrematory 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: P�,� �, o Se,� �r o C Marital Status:
Last Known Address: V �j.C.0
Place of Death:
Sex: QM ❑F Age: 7 % OB: I Date of Death: l(/ /a 4stimated Weight: 0 1ST
Description off casket/container in which remains will be delivered:
6e_. 4. g--L- x C,L-fr,14
PERSON IN CONTROL OF DISPOSITION
(Person(s) in control of disposition, i ' ial 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. 11 1 h. -
g / R 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)
DOS-189844 (Rev. 01/10) Name of Deceased Pagel of 3
I am/ we are the having
person(s) g 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: -
(lnsert from the list below)
Number Dgscription:
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 on behalf of the deceased and who has executed a written statement
pursuant to Public Health Law §4201(7). r
(laffol ALL THREE of the following)
6 ilt A 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 items prior to,cremation may result in harm to the crematory and
crematory personnel. "
�� ►Q I/We hereby affirm that instructions have been given to(funeraldrectornameja�"�i=-,s,�,,�
regarding the removal of any personal property or other thing value which an erson signing below or any family
member of the deceased wishes to preserve. (crematoryname) w; e_ Li /`.
responsible for removal of is not
personal items froYn the container or from the remains of the deceased. Personal items
left in the container or with the remains will be destroye by the cremation process and 'cannot be retrieved
after cremation.
3 R Me hereby authorize (crematoryname)
remains of the deceased. y to cremate the
FINAL DISPOSITION
The person authorized to receive the cremated
Name:__P._;'
Address:
e
of the deceased from th/e� crematory is:
.J,
The cremated remains of deceased will be disposed of as follows:
�� ����P C
Phone: 6 5-� —?a gs -
If for any reason a person named above does not take posses on of the cremated remains,
(crematory name) t`n c v. c L--i is authorized to give possession of the remains to
(funeral home name) -� sM a re_ H 1 by delivery in person or by registered mail.
�o,/1aG� c7sC'\ Ii.C_
DOS-18Wf-I (Rev.01/10)
Name of Deceased Page 2 of 3
X
rf fj!j�t_ial the following)
s
I/We under and that if the remains are not claimed within 120 days of cremation,
(crematory name) " e—U ; C-- may dispose of the remains in an irretrievable manner,
such as by scatte ' g.
CREMATION CONTAINER/URN
(!ad& ONE of the following)
6 KR An um to be used as a container for the cremated remains has been purchased from
SM o re_ }-{-me and is described as follows:
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) will place the cremated remains in a rigid temporary
container for delivery.
This Authorization Form was provide y (funeraldirectorname)
was executed at (funeral home name)
(funeral home address) ��r M d„ e ` � j 6.1aand is signed by the funeral director
as witness to its execution. T
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.
-- ) 20
Signed this o� dayof i'
B r A c co K. _
T or Pnnted Name Signature
Typed or Printed Name Signature
Address
Typed or Printed Name
TNESS:
Funeral Director Typed or Printed Name
66ltd
Registration Number
DOS-1898-f-I (Rev.01110)
orgnarure
l
Name of Deceased Page 3 of 3