York, Michael OF
P IN QUEE9�,53Ur
VTE"I" CEMETERY AND CREMATORIUM
QUA-F-R ROAD,
QUEENSBURY, NEW YORK 128C,
(518) 745-4476 (518) 745-4.477
MM Funeral Director
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emation Started
Time Cremation Completed
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12804
Cemetery Office: (518) 745-4476, Crematorium: (518) 745-4477
Authorization to Cremate
The undersigned requests and authorizes Pine View Crematorium,in accordance with and subject to its Rules and Regulatans to
cremate the remains of:
(Name) l ( )
l"1cX.C u
(State) (Zip Code)
who died on
day of 4-C r 0
at
(P!ace) Tess)
Name and address of nearest living relative or name of
1 u r aut -k cremation:
ct cVeor' NV
(Na (Address)
Relationship to the deceased C A, ar-c
Name of Funeral Home_ �r
IMPORTANT:
I represent that to the best of my know{edge,the deceased has no)p raker defib lator or device in his or her body. (Circle One) =J_ any other battery operated
1 Certify that 1 have full power and authorization to arrange for the c emaU of the remains and to direct the disposition of the
cremated remains,that any personal possessions have either been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View Crematorium from any and all claims and demands for loss a
grst them
reason . or connect with the cremation Of said remains as directed,whether such claims or are or n��"ty
grou lent.
� o e
(Witness) ( e r^t a,Av t C —I —
Addr
v L3.ter vi_ 1 �3I
(Signature and Address of Relative or egal Representative) -----
Signed on this date: T U-
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the Cremated remains as follows:
Mail to
Other arrangements-Please specify:
If pulveriZation of Cremated remains is requested,check here
Revision:January 1,M