Marcotte, A Brian 't.
F' QUEErV,5t3r��,PITYEVIEW CEMETE . Z
RY AND CREMATORIUM
QUAE}z K ROAD, QUEENSBLTRY
(518) 745,4..47.E ' NEW PORK 128pq
(518) 745-4-477
Funeral Director
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case # (13�
08te of Cremation
Time Cremation St e c h� ZO ZO1(�
Started
Time Cremation Completed
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Aut onzation for Cremation and Disposition NYS Department of State
A Division of Cemeteries
One Commerce Plaza,99 Washington Avenue
Albany,NY 12231
(518)474-6226
wwwAos.stale.ny.us
This Authorization Form must be completed and sigped prior to delivery of remains for cremation.
Date: - 10 f o
Number:.
Crematory Name: j ��i/;�,,,n pp��,,��40P
Address: r \ iU,i Ja S�o Phone: 7 Its-- `f'07
/
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 wilt takt �easonable'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 wjll.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.
QPENING 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 thet;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 wilt 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 wilt-be
conducted before a witness and will be done in privacy, with dignity and respect.
IDENTIFICATION OF DECEASED �/►
Name of Deceased: &% el^ A. f " 4A�Ga >��— Marital Status:
Last Known Address: ao R a—I J IV � � a � �.�
Place of Death: ��aa�e f�1 ewor sa , Stiore aQx�
Sex: 1XM OF Age: as DOB: 57/7 &v. Date of Death: J A Slaoto Estimated Weight: LS'0
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 orwritten instrurpe,nt executed
pursuant to Public Health Law section-4201. `
-OR- ' . ..
A•M 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 here remains and (Continued next page)
� (/ l a 1`c�4�C—
DOS-1898-N (Re.v.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 - `
cremation of the remains of the deceased. MY/Our relationship to the deceased is as follows: �
(Insert from the list below)
Number: It Dgscription:
1. A person designated in writing pursuant to ublic 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;.
g. ,k-ctose—fnend-or ielative'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)."
(Inf.lal ALL THREE of the following)
P Pr,41 • I/We hereby affirm that the body of the deceased does not contain a battery,
radioactive implant, or radioactive device and that any such'materials'were removed priorry pack, power cell,
to the execution of this
Authorization Form. Failure to remove these itemd•prio�to;cremattoy result in harm to the cremato
crematory personnel. s. ,., n ma rY and
A'M I/We hereby affirm that instructions have been given to (funere/directornsme"'
regarding the removal of any personal property or other thing of lue which a ,RED,
f k_jny a family
member of the deceased wishes to preserve. (cremat any Pe on signing below or any family
responsible for removal ofis not
oryname) i n,e_v;cw ��f:
personal items from the container or rom 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. -
M
I/We hereby authorize (aomatoryname) r v -�-
remains of the deceased, , y 61_Iel to cremate the
FINAL DISPOSITION •» V��
The person authorized to receive the cremated remains of the deceased from the cremato is:
Name: -D ,Zjl — 1 _ ry
Address: S(yee�► �jv c �,r. , _
Phone: 615-7-- IaSS
The,cremated remains of deceased will be disposed of as follows:
�-e.►g�n�!`-e: c,, It� •a,•i. ;v Z•.'�c.r� =I
if for any reason t e person named abov!Joes not to(cremaloty name) ke possession o e cremated remains,
(Iuneral.home name)
_ is authorized to give possession of the remains to
�+1 S•��r� � •�
by delivery in person or by registered mail.
DOS-1898-f-I (Rev.ovio) PP eAn A' Metrlo Q�
Name of Deceased Page 2 of 3
t
�lni 'I the following)
PAP,- IMe undbrstand that if the remains are not claimed within 120 days of cremation,
(crematoryname) �A^- may dispose of the remains in an irretrievable manner,
such as by scattefing.
CREMATION CONTAINE / IRN
(Ini ' I ONE of the following)
4,A4 An um l-e-be used as a container for the cremated remains has been purchased from
e�sti.�re.- �"0r- l <-),=l - , and is described as follows:
t.w u rl�'
[Me understand that if the urn 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. IMe understand that if no urn is purchased or othenvise..provided
(crematory name) will place the cremated remains in a rigid temporary
container for delivery.
This Authorization Form was prov' ed by (funeraldlru�o name) iD e-64-
was executed at (funeral home name) er+L(
(funeral home address) 1 S�e1'+H.a Ave 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 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.
SLIn d this day of Se,�. 20 ID
JI .rint Name Signature
Address
Typed or Printed Name Signature
Address
Typed or Printed Name Signature
Address
WITNESS: _I
Funeral Director Typed or Printed Name n��ture
0 0 V (a
Reg&ration Number
DOS 1398-f-i (Rev.01l10) Name of Deceased Page 3 of 3