Sr.Jenkins,Christopher �Y
p�E VTEW QUEErV,5ou,
CEMETERY
QUAKER ROAD, ANC CREMATORIUM
QUEENSBURy NEW PORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
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Time Cremation PI Z ZO(d
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Authorization for Crematiori.�.and Dis osition . NYS Department of State
Division of Cemeteries
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1 One Commerce Plaza,99 Washington Avenue
" Albany,NY 12231
(518)474-6226
r -^ www.rios.state.ny.us
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This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date: ���0AP0 Number: 3
Crematory Name:(9JA(A 11/F&J C#?e ,9jVR 1u M
Address: Wi52_7W. " GadQ Y/ I11'X ����!� Phone:
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 take reasonable efforts to remove all of the remains and other'matenal 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.,lf 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'witn,ess.and"lwill'be,done-in.privacy,with dignity and respect. s J
IDENTIFICATION OF DECEASED
Name of Deceased:C��f IS TD®/"E� �� '�-��K�A/Sr . SR. Marital StatUs:C Imo,
Last Known Address: /S]�/Op-. LLG ( fJ, ���ae .44 V J�
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Place of Death: kPjT.4 L. `
Sex: A [IF Age: DOB: /� !� Date of Death: Estimated Weight: /gyp
Description 9f caskettcontainer in which-remains will be delivered:
&voo ev,00 D e 0)77P6'9 17E 63 07m
CARO .,2,.49, 7-0
PERSON IN CONTROL OF DISPOSITION
(Person(s)in control of disposition, 'ni al ONE of the following)
am/We aie the designated agent of the deceased designated in a will or written 1nstrument�executecJy;' `
pursuant to Public Health Law section 4201.
I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law
section 420.1 or a will containing directions for the disposition of'his or her remains and `(Continued next page)
f
)OS-1898-f-I (Rev.01110) Name of Deceased Page 1 ow `
1 am/we are the person(s) having prig ity under Public Health Law sectiom4201 and have the right to authorize
cremation of the remains of the deceased. My/Our relationship to the deceased is as follows: * r
(Insert from the list below).
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; -�>
6.A surviving sibling eighteen years of age or older;
6.A lawfully appointed guardian; T �'= •- K
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.§420�1(7);
10.A chief fiscal officer of a county or a publio administrator appointed pursuant to the Surrogates 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)
N 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
1070 crematory personnel.
hr� I/We hereby affirm that instructions-have beengiven to (funeral directorname) C RW25 X M09-SPOA1
regarding the removal of any personal property or other thing of value which any person signing below or any family
member of the deceased wishes to preserve. (crematoryname)(Y//��IiIJ CR�7 ��� 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 destrdyed by the.cremation process and-cannot be retrieved
after cremation.
[Me hereby authorize
_(grematoryname)&//✓GNU/��.G�/����TO4?I. M to,cremate the
remains of the deceased. •� y k • *, .�, ,r' ".f _ `
FINAL DISPOSITION K N -
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name%Sjgane5 X 4WAg4i(/ �20
Address: rOt?7- PAW. IV Phone:e ,�J'''.��'S��
The cremated remains of deceased�will be disposed of as follows:
OEW JqN—1=0 7—V
If for any reason the person named above does not take possession of the cremated remains,
(crematory named NE!// G�d��w}77�3 Td eQ lGl rl'1 is authorized to give possession of the remains to
(funeral home name) by delivery in person or by registered mail.
. , Ca�}D�.lS f'� fit'•� Vi �lAo S
n s
DOS-18984--1 (Rev.01/10) Name of Deceased Page 2 of 3
(In'' following) r
—P' Me understandlhat if the remains are not-claimed within 120 days of cremation,
(crematoryname)6"1A1 jWlZD&d Rjg llT&*3021MIA may dispose of the remains in an irretrievable manner,
such'as by scattering.
CREMATION CONTAINER/URN
v
(Initial ONE of the following)
An urn to be used as a container for the cremated femains has been purchased from
and is described as follows:
Me understand that if the urn is too small to hold the entire cremated remains, an additional rigid container may be
used for delivery.
-ORS
1� An urn has not Wet been purchased. I/We`understand that if no urn is purchased or otherwise provided
(crematory name)&l W CIZ6W.477R/lC AA will place the cremated remains in a rigid temporary
container for delivery.
This Authorization Form was provided by(funeraldirectorname) A/ ,
was executed at(funeral home name) AW09-710AI F&MAE PSG
,
(funeral home address) f 4- d?r RA14 N 2 and is signed by the funeral director
as witness to its execution.
I/We have received a completed copy of this Authorization Form.
The persons) 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.
Signed this C:V1. � day of -9 AVT 20 A�'.
Typed or Printed Name Signattir0 I in ON
Address
•w
Typed or Printed Name Signature ,
Address
Typed or Printed Name Signature
Address
WITNESS:
Funeral Director Typed or Printed Name Funeral Director Signature
'7 � o d's
Registration Number
DOS-1898-f-I (Rev.01110) Name of Deceased Page 3 of 3