Hart, Nona TOWN OF QUEEM,50UPJ"'
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD. QUEENSBURY. NEW YORK 12804
(518) 745.4476 (518) 745.4477
Funeral Director
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1'OWN 01= QUEE14SUUIIY
PINE VIEW CEML='rERY
3.
CREMATORIUM
Quaker Road. Queensbuiy. New Yurk 12UU4
Phone tG10) Cren�atoiium 745-,1477 (if no answer)
Cerrietery 74v-4476
AUTI IORIZA VION 'I O GREMA l E
The undersiyned requests and aullmizes Dine View Cienwlunuin. in accuidance with and subject
to its Rules and Regulationis l /
to ciemalee.the iemains ul:
(NAME) (SEX)
(STREET) (CITY) (STAI It) (ZIP CODE)
who died on day of _20Q,�"=
at s , d2 C
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Relationship to deceased
z'&�t-'-'
Name of Funeral Home
IMPORTANT
I represent that to the best of my knowledge, the deceased has or(�iasnupacemaker In his or her
body. (CIRCLE ONE)
I certify that I have the full power and authorization 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 Pe destroyed, and agree to protect, defend and save harmless Pine View
Crematorium fr any and all claims and demands for loss or damages which may be made
against them reason I or connected with the crernalion of said remains as directed,whether
suc ims deirnan5rare or are not wholly groundless, false or fraudulent.
IT (AD SS) /
(SIGN EOFRELATIVLvOR LEGAL REP. AND ADDRESS) n
Signed on this da . •