Areizaga, Carm TOY N OFQUEE9�5BUPJ/-
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director C; AIaZ_�_--rU t-k
"re_ Ag'r/ r7- 46 Cases
ace Of Cremation / _ O
=Me Cremation Started G 5
' :Te Cremation Completed 10 �
Pe of Container
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TOWN OF OUEENSBURY
PINE VIEW CEMETERY
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 an/d�Regulations to cremate the remains of:
xl'rf
(Name) (Sex)
x �I Oh,' /&-?O L/
(Street) (City) (State) (Zip Code)
5f'
who died on , 1 day of ' �i�
at l Vl1�
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
(Name) (Address)`
Relationship to the deceased _x
1
Name of Funeral Home
IMPORTANT:
I represent that to the best of my knowledge, the deceased has has no cemaker
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 reason of or
connected with the cremation of said remains as directed, whether such claims or
demanos,are not wholly groundless, false or fraudulent.
x j U7C,
(Address)
X
(Signature of Relative or Legal Rep. and Address)
C7)
TOWN OF OUEENSBURY
PINE VIEW CEMETERY
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:
x (AM&PI lm
(Name) (Sex)
x 21 Brandon Rd, Yonkers, NY 10704
(Street) (City) (State) (Zip Code)
who died on_ day of ^,l�-Q.�r 2-003
at Pine View Crematorium, Quaker Rd, Queensbury, NY 12804
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
x
(Name)
Relationship to the doceased_x .r
Name of Funeral Home
IMPORTANT:
I represent that to the best of my knowledge, the deceased has has no Pacemaker
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 iray be made against them by reason of or
connected with the cremation of said remains as directed, whether such claims or
deman are)not wholly groundless, false or fraudulent.
x
(Address) U� 7
`
(Signature bf Relative or gal Rcp, and Address)