Lynch, C. Mary '1-1-1 wN OF QUEEN,5BUPy
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director , \ T�
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17e Cremation Completed
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office'(518)74.5-4476,Crematorium: (518)745-4477
Authorization to Cremate
The undersigned requests and authormes Pine View Crematorium•In accordance with and to its Rules and Reputations to
crgmate the remains of -
(Name (sex)
(Street) (City) (state) t
who died on a_ day of 20 0-CP
at_ h t�� Q�._
(Ph") (Address)
Name and address of nearest living reta8ve or creme of person authorizing arernstim:
(Name) ( --(Address)
Relationship to the deceased
Name of Funeral Ftorrie --
IMPORTANT:1 represent that to the best of my Ivtowledge, or the deceased(has)or(has no)pacemaker.ddbrft or any Ww battery operated
dwAm in his or her body. (CNde One)
I ON*that I have full pourer and authoraatim to arrange for the cremation of the remains and to direct the disposition of the
«emeted remains.that Any personal pomm"lons have ekher been removed or may be destroyed,and agree to protect,defend and
saw harmless Phe Vow CM1n1W luin from mW and all claims and demands forloss or damages which may be made against by reason of connected cremation said remains directed,whether such claims or demands are or tltern
no
t wholly
9rundlesZ( ari
e►a.
— (Address)
" d of Relative or I so Representative)
Signed on this date:
Disposition of Cremated Remains
1 hereby direct mine View cmff otonum to dispose of the cremated remains as bBow
Maitto__
O#w�-Fw W WSC y.
If pttion of cremated remains is requested,check here _.
Reviskxi.Jmxrray 1,2006