Graham Ralph A •
• TOT1N
PINE VIEW `�" �J'�'B�•
CEMETERY AND CREMA '�/
QUAKER ROAD, QUE SBURY TORIUM
(518) 745-4.47,6 � �W YORK 12804
(518) 745-4-477
Funeral Director
3ne enSmort
L-t� AN •
Case _ 1�Z
Date of Cremation
Time Cremation St , Ofb
arted
2 16
Time Cremation f
Completed 3 60 Y'
TtOe of Container_ ove L.441.emar5 • °wdC
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utI jorization for Cremation and Disposition NYS Department of sbte
t Division of Cemeteries
_ .. t = : t t-" ,c•': One Commerce Plaza,98 Washington Avenue
L • - Attiany,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: Se 1 `f ! Number: w '4>.. '-
P k Z`� k,,).v
la
Crematory Name: i,i e v;c0 (-rc,..,.,-{-o(`:...,.�
62,4 a1/(e r g _
Address: c�cis c....., N,j 1 iAwC9'7, Phone7 -'/'(7
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS. j ,
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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 meta!,,which are alI that will be left after cremation.
Following cremation, the crematory talc ea'sonable eff,orts.to remove all of the remains•and other material from
the cremation chamber;but someminimal'd'ust•and'reaidue'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 wjli:be.mechapicaliy pulverized into small pieces and placed into a ''i''c•, . �°
designated container or urn. Cremated remains generally are pulverized until no single fragment is 'rys
'recognizable as skeletal tissue.
OPENING OF CONTAINER
The crematory may only open the container holdipg the un-cremated human remains in limited circumstances, such
as to confirm the identity of the deceased or ensure,thet,no material is,enclosed which might injure employees or
damage crematory property: If human remains are deliveredin,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' :.i.. ''%
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: wL k_ 4 4r a,,,` . . Marital Status: (A-,%`t°`-'e-ck.
� fRLast Known Address: �j nS +�(� '�a� / r l M+) 0` � Y�7 p .
,.
Place of Death:___ S�r``�`'-: V. ��'�;
� . e� �
: li( t e2tcl& A t!L N �
Sex: UM OF Age:�'[ DOB: ) ^v )
�o% r7 3i Date of Death: �!//3�j 3 Estimated Weight: I S-c)
Description of casket/container in which remains will be delivered:
{ ,.
rI a
PERSON IN CONTROL OF DISPOSITION r` '
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.
OfZ
. . •
D I/We have no knowledge that the'deceasedexecuted a written instrument pursuant to Public Health Law
section 4201 or a will containing,directions for thedisposition of his or her remains and (Continued next page)
1?aZink / , • r�k 4A'1/4
DOS-1898-f-i (Rev:01/1'0) r Name ofbeceased
4Paget,of3
•
I am/we are the person(s) having1
P O priority under Public Health Law section 4201 and have the right to authorize t-
cremation of the remains of the deceased. MylOur relationship to the deceased is as follows: - ii ,`
(Insert from the list below) '\\\
Number: < Dgscription: Sr.-' .� S b.L` •
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).
(Initial ALL THREE of the following)
3) 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 itemt•priorto,crematJdn'may result in harm to the crematory and
crematory personnel.
t t I/We hereby affirm that instructions have been given to (funeraldirectorneme). Rol et i-- I - c-hsAnar<—
regarding the removal of any personal property or other thing value which an person signing below or any family
member of the deceased wishes to preserve. (cremator/name) i�c_v;c_t,, r".c4-o f:•,,,,� is not
responsible for removal of personal items from'the container r 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) PA e V:ct_.-, Gc .tip r,•-•„� to cremate the
remains of the deceased. — ,
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name: 1 0,6 e r-C--- _1 ��
Z'ihSMa rL 401 Mai-L l:4ce,t.. o..n e -Le -
Address: / Ske.r,,, Aae� �1•;441,� N i Zaga� .. Phone: 4ST`}"- 9a8S
The cremated remains of deceased will be disposed of as follows:
6:-,..,,-. 4 �,, L ... _.
. .
If for any reason he person named abo does not take possession of the cremated remains,
(crematory name) i n e v:c v C("C' """ f` j 4'‘
is authorized to give possession of the remains to
(funeral home name) �C..-t S M o r c_ L '--1 o •.
`-��+t r� Me 1^ by delivery in person or by registered mail.
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DOS 189 1 (Rev.01/10) Name of deceased Page 2 of 3
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Dt e. I/We and stand that if the• emairis are not claimed within 120 days of cremation, t t.ti 4 t.:y,Z ,
(crematoryname),,. . i 4e Vt.C-w c.,• kto r!-'M ma ,dis ose ofthe.remai s i -
suchas ✓Y scatte - yip', n n an irretrievable manner,
11••,� ..:rur: •':-Y. -:a.-sd+ya:.•ihh��t--, 7' :'m' .s,'s:..c`.'r.--,'3�i-nl'--'.'f�.'r.¢4..Lti a'4"�i- v.:C''':---fi;. .r
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t a fnA °T`+• a''fi4k:u ..� � i?:d";'hs a-z:. ' er .y`' ''v, wk x
a�a. e*,-x�d�'x>is •>�:z w'�, t.' .R�ffa!:• s i�3e�; s>"s B: 5.i'�'�
CREMATION-CONTAINER/URN - "` -. '-_r •-—" 4- '-'�- �T • — _ - __
(Initial ONE of the following)...-- . „.,. ,.., _ i`j' '''lblaj.•_-_- _ .
15 6" An urn to be used as a container for the cremated remains has been purchased from
„?e i M 6/4e.I•",t0:A t r..L l-1,M c_ and is described as.follows:
ii0,s i - M-c-/4.L. LA.f. .
IANe understand that if the urn is too small to hold the entire cremated remains, an additional rigid container may be
used for delivery.__,.��_�. .A --_.., ...,...� - ..,-Y � . _.. .V.. ,`�.�.,__ _
_OR 4 .-•.r 1£k'k,'.1 :�� A-% ,7'-r ..i,..-^,A ,.t ,to !w.'n.{r-. 4 4* 1 i'0 •'ef 5
fT } wiic 1 3u' ^rtf rti 11t,v.i'PI 13.i'1,,4,1 j'fil S re iuliZ Z kI; !i l l6ciiS.r,4 and it,��:4:ZwCf-:441:n r al" ,i[J ita..!h.�•Is tf)(o
An.um,has'.not yet beep purchased, :/.e;u. derstand,that�if-no,urrl;is pure as d"or,otherwise provided,.,,;
"`"'` ill lace�the cremated remains.'
�.-� sh t,.��, -�: 3��xni�;4�:r,d��:,�f��' ��;�_,.fiY�� 1,'.�W 1p in-a rigid temporary
(crematory`name) .c `3 k �.xi`• :�• �r>" p t� t }� t }t container f tS, }'.i,-A.i'K;� to lii fi:. E Yk S `p i 1.1. ii'lr,=;v+'".�iie!s rjt tt ya+fimiy. t ;A. 1'1:1'f Cam, lt!..45+ `6f2 ,,-;44m
ordeliver� ��:;� t' •if��'f�=3a•_��..<i:t:t.��>,k �' -�•xl�5
i 1., t`r ,, ;ly.a rn,,ra It; t_It'z rn x 'rarcire' -of tir •t.i} ill:�
"�, t. ! PTn '�L-z=r �;u.>?.. �E �' �Yf��'�� �.7t~¢� �++a{V, � �^' ) r roc _
�¢ .t- .Y�., d.a 4_ will 31+"use liC< .Ct. �, k, t( c,- -.'
11 l{..a?.;l i".,#7 k. ry a. Fl �t.,,y f Te,`$''T^� r".`i'-ri- a a�',,..`lt r�^ 1 S t' C � R�t,Rya,w=j .ii �•V�L.: ti+
a. .ii •tj4�rtic-x••,t '!.e'. r,kri !i1e com.. l,..rf"iri j rn'�"f''°.z i:,:�ry 1 1.>. ILiz iiii. !C+� 0...,PCi ii4 1
i i . . 'tS t A' rr 4a ;5�.1e yc a'k � x•.i:., � .,! f 4 �,,.
This Aiithorizatio` r" 't n Form wasrovi d by;�fi;'nere`�'drect: ,am j t'J:�1F � +• ;axe" i>\sw r=mot t=y
! SI^ '^' r.rtir3li.j+ 3. p,'i"4h 4. !' ef,.� 1 n t«. C�. _
•Was executed at' to eia = Is ' #�ti -;4./ _�,. s�:—sCa + i :. ..r 7i.ir t� '�� 36s. s�
,,! , (, n lhomename),.�� P�SMoPL �%1er L . =,..1.c-2 1�c• . - 'ia�;-'
(finera/home address)` L�S U�,� AV e- Gt-.cl .r 0 _ 1a C?.)- and is signed by the funeral director
as Wit nessTto'tts.execution.Z
,,,,,:to i?ny 1,s{ ti,,:-g„,i tT 1,.. it.'f{,Arli lr.":e tfwI;4441 te:.4,ic'`•47i•-4. ' a.f; 1• r, f
- �A c•,• u I c. t.^.Y... „, via lrt .11.''sG { :[ -
I/We hav P py t0:-.. '- R,..
e r`eceived a com letedco 'of'this Auttiorization'Form.'��-��' � '« - -:�-•;= t .:c'it <1„-, 0, .1 , 'a• . -
The person(s)yidentified below's/are,thet person(s)in i n� ` 'n'of o 'sp•.F , ' ` gt 1 °�!� 'Yf
�. ..,, pe n(s)�i control f disposition,iivii-i .'•t Igning•tfif eI a
AuthOnza� .r. r • "e •.�thera � �" '§ � !' 3'" `4'„9 a. � a # "�...Le��;.t..
�t1on Fo attest(s) • '°`b ,_ ��, gym, Y` ilgCCt•••• o and completeness of the Info..• 1 n contained In„this ,
•.. : � ..'. ,�# 's',t ti,...,:!t.G+.i i4.'r � e.:=' :�1-• t .. • t. w; G..r M ��! t
Authorization Form and.authorize(s)thoforegoing i,�_t { t n�r1} ,,,
• r�. .: try t ri i � Y ��:ilia aa;�`�k'A`�i i���=L'ei�A.i 4��.S f.J'3,..A
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Signed is:-. 6 7 . day of 5. "L-ry °".-/' 20 1-05:42...e. ,,
J..)7at NA 4. L A J. k''.<-.4,-)f-r,--;--i.a.
Typed or Printed Name_; k
rl f O S ) e r, his /�.'w...,._pcet1'-Ft BC ., _p i � ' • 'G G tt '` ,• .. .
Address'I .,: %ir:s '."/ (� ,/`,'` t. t�o.
I/ l•�>_..•e.x,l" ..mot..,.=..+.,...A./. ,-.........,.•.
Typed or Printed Name
1.t .J A t F ;.._tt •♦ 1.7•.'a:: .3T .N.4rntt•1• Z An , a . al
Address YI '
7. ,.Lt' )to,i- XS' :F!.'-. t ( ..,,,r r a ?.•` vie ...11.4 ',`. .:u=.� - :�: ..w`• v!a
Typed or Printed Name ;Signature
Addres .'- ,f i/tii 4-"ti"t..'.:??'.. }.`_ '14 ' _
`j ;�r• ;r lI(. 014. ,'1 .tAi;Ci''."t CM.. fitC teTii r..7 .WJNESS• t+ v al. ' .4?..-,iti:''1at.d€v-lent d the unr--a,-. 1,,- • a „
- .Funeral Director Typed or Printed Name neral Dire or Slgnatu
Registration Numberald#.'t ,,,: ',7.r4'vi;:x,nr;`,boat felf)T.A 8'5' l:i w e'ff 14r0r��°.1�'4 3,c�{;:ittf,-.k y:ti„1.1, i[1 l tIt-4 "i-:41-Nhk „ 'sy
tt fa y t .�� L:.i.i.a�.,{;-js•Sa b't R�.,.t ik a�b.t: 6 Ani I f a3�-,�c` k
1.,,- .. ; r 420 i nr 1 v"'.` h k .r ;� Ai !", ,r A•i.,,t rkfi. ?..
t,� 'i:�fic�;1;_S ai�a..:�,,;,.Fu=5 tf�.!;r s'.F:a�.ytiF'�l{�ik�i�i#�v or f.': -.;r• . ,.t`fit" 't'` c•
/..(.../ t...... Al gr ekk 4, ... ..,__
DOS-1898-f-I (Rev.01/10) Name"of ased Page.3 of 3