Houseworth, Jill A Town of Queensbury
Pine View Cemetery and Crematorium
Quaker Road, Queensbury, NY 12804
(518)745-4476 or (518) 745-4477
Funeral Director &fQL- c P�Ma
Name J i �� �IovSewv��L Case No. 67 1
Date of Cremation NO.M ,6A-r to, 70 1b
Time Cremation Started
Time Cremation Completed 3 Z(5v h
Type of Container (ArAcla/j SF(OOD CA-6E.
Remarks
3:a s'ph
n� T
%tom NY$Depa►iment of State
Authl'orization for Cremation and Disposition Division of Cemeteries
Ono Commerce Plaza.99 WaaNngton Avenue
Albany.NY 12231
(510)474-6225
www.dos.slato.ny.us
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date: Number. �z
Cr Name:
Crematory
Phone: � �Address: cc �"/
17-.
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 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 O�DECEAISED /
Name of Deceased: - �U�lt�� i Marital Status:
Last Known Address:
Place of Death: � laig ��✓'
Sex: ❑M F Age: DOB: �' Date of Death:.12
�arJEstimated Weight: j 7�
Description offccasketicon`tainer in which remains will be delivered:
PERSQN�N_CON7Rt1�Q�pI�PQ�I�Ot�
(Person(s)in control of disposition,kou ONE of tho 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.
gion
I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law
201 Ora will containing directions for the disposition of his or her rema'ns and (ConGnu nextpage)
OOS-18913-t-I (Ray.01/10) Nam*of ocoasoat Page 1 or 3
}
k
I ami 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 Description:V— -04�
1.A person designated in writing pursuant to Public Health aw section 4201(3);
2.The surviving spouse;
2a.The surviving domestic partner; y
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;
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).
X- THREE of the followine hereby affirmthat the body of the deceased does not contain a battery,battery pack, power ceve 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
are story personnel.
Me hereby affirm that instructions have been given to(funeral c recWrnama) G moo'
regarding the removal of any personal property or other thing of_valu hich person signing below or any family
member of the deceased wishes to preserve. (aomaroryaamc)� / lZr It - Z--k/ 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
trei—ns
emation. �—
I/We hereby authorize(mmarory namo) III-ejao-w-�f plt�l� to cremate the
of the deceased.
FINAL DISPOSITION
The person authorized to receive the c mated remains of the deceased from the crematory is:
Name:JFl� s
C .
+
� P - �l
c � —Address: one:,
The cremated remains of deceased will be disposed of as follows:
If for any reason the per
dame a ve dosstake-possession of the cremated remains,
(crematory name) '�6Ze ✓ vim` is authorized to give possession of the remains to
(/�nor�lnomvnomo) v��Gyi by delivery in person or by registered mail.
DOS-1898-r-I (Rov.01/10) Name orpo=sad Page 2 of 9
following)
�- I/We un Tatand th t if the rqMains are not claimed within 120 days of cremation,
( rorrr•�rory namo) a/D may dispose of the remains in an irretrievable manner,
such as by scattering,
CREMATION C-QNjALNERIU.RN.
1
/ (initia►ONE of the following)
An urn to be used as a container for the cremated remains has been purchased from
and is described as follows:
1/We understand that if the um is too small to hold the entire cremated remains,an additional rigid container may be
used for delivery.
O - _
/ An urn as not y 'been purchased. I/We understand that if no urn is purchased or otherwise provided
crematory namo) /,? -e .,. �t? ��� r1'ft4 will place the cremated remains in a rigid temporary
container for delivery.
This Authorization Form was provided by(funerai&&vornamo) CP
was executed at fiunnccrw home name)
(luneraf home address) /1%��Z� / G/�.s' owe iti�l and is signed by the funeral director
r
as witness to Its execution. d�!
I/We have received a completed copy of this Authorization Form,
The person(s)identified below islare 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.
sictned this day of v'el-Z, ,
at/W- O� �J�� 1 �
Typosinfo Mwe / 7 Cvyl4�ln ✓v - /�tJL .
C/ L
Address
Typed or Printed Name Signalure
Address
Typed or Printed Name Signature
AddreSs
WITNESS:
71-
Funeral Director Typed orPrinfed Name Fri. ra clor 51gna[
KagutraGorr u
DOS-18984--1 (Rev.01110) Name of Deceased Page 3 of 3