Satterfield, Robert r.
PWE VY J QUEE9�sour)
EW CEMETERY AND
QUAKPFt ROAD CREMATORIUM
QUEENSB(TRY, NEW YORK 12804
(518) 745.4476 (518) 745.4477
Funeral Director
Fame �.'„� art C n
08te Of Cremation Casey.
r
Time Cremation Sta ZOp
Started
7 :me Cremation
Completed 3, /,p
Type of Container
Remarks C
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12804
Cemetery Office: (518) 745-4476, Crernatorium: (518)745-4477
Authorization to Crernate
The undersigned requests and authorizes Pine View Crematorium,In occwdance with and subject to Its Rules w of Regulations to
the
«T�b'rfremains
----
(Name) (Sex)
(Street) . (City) \ ate) (zip Code)
who died on `� day of
at7 --
(Place)
Name and address of nearest living relative or name of person authcxizirrg cremation:
JA
(I14ame) (Address)
Relationship to the deceased ------ --— —--
Name of Funeral Home t 4 - ----
IMPORTANT:
I represent that to the hest of my knowledge,the deceased(has) r has )pacemaker,defibrillator,battery,battery pack,power
cell,radkxactive implant or radioactive device In his or her body.(C a Or )
I certify that I have full power and authorization to arrange for the cremation 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 ail claims and demands for loss or damages which may be made against them
by reason of or connected with the cremation of said remains as directed,whether such claims or demands are or are not wholly
groundless,false or fraudulent.
(Witness) (Address) —---- --
-DD.t �andess --
S�( 'rgt Relative or Legal Representative)
Signed on this date: 'l ll �ko - — -- --
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as fellows:
Mail to
Other arrangements-Please specify:
If pulvertzation of cremated remains is requested,check here _
Revision:April 18,2007