Lockhart, Dorothy • �a
T014N OF QUEEN,50U
P\�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4.476 (518) 745-4-477
Funeral Director j;'OC,�F��;�y r�G
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ate Of Cremation ell,
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Ke-narks
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TOWN 01: QUE=ENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road. Queensbury. New York 12804
Phone t516) Crernatoriuni 745-4477 (if no answer)
Cemetery 745-4476
AUTHORIZATION 10 CREMATE
The undersigned requests and authorizes fine View Ciernatumm. in accurdance with and subject
to its Rules and Regulations to cremate the remains uf.
(NAME) (SEA)
) yt (.
(STREET) (CI tY) (STATE) (ZIP CODE)
who died on L day of )\Jcr'.! 20e3
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Relationship to deceased
Name of Funeral Home
IMPORTANT CLiasnc)) acernaker
I represent that to the best of my knowledge, the deceased leas o in his or her
body. (CIRCLE ONE)
I certify that I 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 reaso r connected with the cremation of said remains as directed, whether
such clai s or e a s a e or are not wholly groundless, false or fraudulent.
„J .�
(WIT S) � (ADDRESS)
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date:»/,�