Koshgarain, Donna TORN OF QUEEN `Ll-WY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY. NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Named��YD i�����/�/4r Case #
Date of Crematicn
Time Cremation Started M
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Time Cremation Completed [ r 'l'� plVt
Type of Container
Remarks :
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• TOWN OF QUEENSBURY
PINE VIEW CEMETERY n
b /CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
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 :
(Name ) // (Sex )
(Street ) � (City ) (State ) ( Zip Code )
who died on /7 day o f D���J�� _ 19
at SAfh �u5 S4fAia r.n
(Plac (Address )
Name and address of nearest living relative or name of person
authorizing cremation :
(Name ) (Ad ress )
Relationship to the deceased_/-a a o .
Name of Funeral Home
IMPORTANT:
I repreeAt— to the best of my t,nowledge, the decea ed has or
has o pace_m_1t4er in his or her body. (Circle One)
I cert ' +ra-t'T have the 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 all 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
g oyndless, false or fraudulent .
(�litnes
(Address )
(Signature of Re�ative or Legal ep. and Address)
Signed on this date :