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Pfaff,Daniel ,t T QUEE-V., OQCEMET ��../ QUA ROAD, QUEEN 9 ANC KER CREMATORIUM VRY, NEW YORK 128N (518) 745-4476 (518) 745-4-477 Funeral Director pfs�� 7 fi Casa # ��7I 08 " Of Cremation T =me Cremation S m ZU ZC)10 Carted a CL i =me Cremation Completed � =z3 T fae of Container /11 I n n rC b dq rC.� CQ p v =emarks °v 6 2,'1 P h- Z;S©�� 1 NY$Department of 5lato Authorization for Cremation and Disposition Division of Cemeteries Ono Commerce Plaza.99 Washington Manua Albany.NY 12231 (4-16)474-6226 :. wwwAos.stato.ny.us This Authorization Form must be completed and signed prior to delivery of remains for cremation. l' d Date: I Number ..� Crematory Name: Address: .fXc am' /v Phone:_ ' �� CREMATION IS AN IRREVERSIBLE AND FINAL.PROCESS. 4V I'll 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 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 /� Name of Deceased: r�� ZX 7—r- Marital Status: Last Known Address: Place of Death: Sex: 1�1% OF Age: DOS: Date of Death: I-ZZ�11-2 Estimated Weight: /cam Description of casket/container in which remains/will be delivered: RERSaiV��!_GONTR�I�O�P0�P4�1�'ION (Person(s)in conbof of disposition,k4W ONE of thv 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. -O - !- IiWe have no knowledge that the deceased executed a written instrument pursuant to Public Health Law sec ion 4201 Ora will containing directions for the disposition of his or ker remains and (Continuednextpege .� - oos-iWU-r-1 (Rov.ovla) Nam*ofvoca sod Page 1 of 3 K 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/fst below) c 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 islare closest in relationship to the deceased; B.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). (lrririal ALL THREE of the following) IA A/e hereby affirm that the body of the deceased does not contain a battery, battery pack, power cell, ra loactive 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. (�I/We hereby affirm that instructions have been given to(runemickmotornamo)�U6m4e's C' O� regarding the removal of any personal property or other thing o v4lue which any peon signin below or any family member of the deceased wishes to preserve. (cmmatory � LLnamo) l� -C�� k2t� -/c. is not responsible for removal of personal items from the container or 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(crnmwory namo) D/�?-C !/!�� .�f�I�i��'!L' to cremate the remains of the deceased. FINAL DISPOSITION The person authorized to receive the cre ed remains of the deceased from the crematory is: Name: Address: J - ��d j / Phone�l� The cremated remains of deceased will be disposed of as follows: If for any reason the person named above dos not take possession of the cremated remains, y (crematory name) V1-e is authorized to give possession of the remains to (runonl home?name) by livery in person or by registered mail. _ L DOS-1898-t I (Rov.01/10) Name erDecuoseo Page 2°t w, = following) IIWe and rstand that if the r ains are nit claimed within 120 days of cremation, (cromatary name). !-e h?cr/d rt vim__may dispose of the remains in an irretrievable manner, such as by scattering. CREMATION CQNTr0.1NERtU.RN. ( '.al ONE of the fallowing) An urn to b used as a container for the cremated remains has been purchased from �- 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 Tor delivery. -OR- An urn has not yet been purchased. I/We understand that if no urn is purchased or otherwise provided (cramafory namo) _ , will place the cremated remains in a rigid temporary container for delivery. This Authorization Form was provided by(runewdiectornamo) -P dz;7— . was executed at(funeral horrtg name) .� C 4 -- I h c t (funeral home address) / „r;rf and is signed by the funeral director as witness to its execution. 2-07 I/We have received a completed copy of this Authorization Form, The person(s)identified below istare the person(s)in control of disposition,who by signing this Authorization Form,attests)to the accuracy and completeness of the information contained in this Authorization Form and authorizes)the foregoing. Signed this e day of ,20"d Typovne Sig atu `2aI)4 f1;raw. Y)i- ��d �-n-I a Address - 1 �' Typed or Prmled Name Signature !Address Typed or Printed Name Signature Address WITNESS: Funeral Director Typed orPr;nted ame F•ur)a cl6fiftnalura a2c-?f 7 RagWaGorr Numnur S: / 617 DOS-18%4--1 (Rev.01110) Name ofDeaessed Page 3 of 5