Market, Joan TOwN OF QUEEVBUr�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Y� �1^ ,/� Funeral Director
Name � � 1 �.� / ► � I�I���LF�
Case#
Date Of Cremation
Time Cremation Started
Time Cremation Completed
Type of Container
Remarks
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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 Regulations to
cremate the remains of.
Mama) (Sex)
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Is 7 � y
(Street) (City) r_ ( (Zip Code)
who died on S� /� Q
of �J U.�1 z�� 20f
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Name and address of nearest reladv- e.-e or name of person
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(Name) (Address)
Relationship to the
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Name of Funeral Home �= (�-
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or no) ,defibrillator or any other battery operated
device in his or her body. (Circe One)
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 aN clalrrrs and demands for loss or rim rrnages which may be made against tlnem
by reason of or with the cremation of add remains as directed,whether such clahns
f or de Twxiis are or are not wholly
wholly
grommem
falser
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(signature and Relative or Legal Rive)
Signed on this date: X1.
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as Mows:
Mail to
Other arrangements-Please specify:
if pulverization of cremated remains is requested,check here
Revision:January 1,2006