Dunn, Thomas Tow�'� OF QUEE9�5BUP�-y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director -.;?- 1 =
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TOWN OF QUEENSBURY = -
PINE VIEW CEMETERY
&
CREMATORIUM
Quaker Road. Queensoury, New York 12804
Phone (518) Crematorium 745-4477 (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:
-- Omcts
(NAME) (SEX)
(STREET) (CITY) (STATE) (ZIP CODE)
who died on day of V20
(PLACE) (ADD SS)
Name and address of nearest living relative or name of person authorizing cremation:
L f�iYSTi¢,o� G—, L Z>i, 'i4kb s
Relationship to deceased DA;eZ;/17Z7_R
Name of Funeral Home are f u`� rrA1 Y1�
IMPORTANT
I represent that to the best of my knowledge, the deceased has oKI as n acemaker 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 errand�e or not wholly groundless, false or fraudulent.
(WITNESS) (ADDRESS)
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS) _
Signed on this date: