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Summerville, Harold ± �o r�,N OF QUEEM 5B U Y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD. QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745.4477 Funeral Director a'e Hn xzo •.r) `�U AA/JA r/,1.�-�- Casey Cremation 200 Cremation Started -e Cremation Completed I d e of Container t?, ,11/1t1, ��,) © ��l arks 11 .2 i i i i TOWN OF QUEENSBURY PINE VIEW CEMETERY&CREMATORIUM Quaker Road, Queensbury, New York, 12804 Phone(518)Crematorium 745-4477 of 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) who died on day of 20 at (Place) (Address) Name and address of nearest relative or name of person Authorizing cremation: (Name) (Address) Relationship to the deceased Name of Funeral Home IMPORTANT: I represent that to the best of my knowledge, the deceased has or pacemaker in his or her body. (Circle One) ° I certify that I have the full power and authorization to arrange For thercremation of the remain$-wd to direct the disposition of the cremated remains, that any personal possessions have either been t'tamoved 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 wholZgrrLod�less, false or fraudulent. itn (Address) 1 (Signature of Relative or Legal Rep. and Address)) Signed on this date: