Adelson, Gordon TOTS OF QUEEN,5BURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
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PINE VIEW CEMETERY
CREMATORIUM
Quaker Road. QueensUuiy. New Yoik 12UU4
Phone (518) Creniatoiium 7,15-•1477 (if no answer)
Ceme.teiy 745-4470
AUTHORIZA]ION '10 C REMA l L
The undersigned requests and aullmizes Pine View Gienwtumim. in accuidance with and subject
to its2710'_z>0'4J
s and Regulations to cremate the remains ul:
Ytd2�<�otil nil AL6
(NAME) (SEA)
- 0 OLt,> cm�_- a fzb, ez�,vs l a&)
(STREET) (Cr ) (S I A I L) (ZIP COD PH)
who died on L( � /_ clay of 206
at / 6/'2A�A `0b & k
(PLACE) I (ADDRESS)
ame and address of nearest living relative or nalne of person authorizing cremation:
Relationship to deceased
` J
Name of Funeral Home
IMPORTANT
I represent that to the best of my knowledue, the deceased has or has no pacemaker In his or her
body. (CIRCLE ONE) '
I certify that I have the full power and authurizalion to arranye 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 ims or demands are or are not wholly groundless, false or fraudulent.
(WITNESS) (ADDRESSS)
P?RATr OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: /3 le