Levin, Florence TO gti/N 0 F QU E�s5B U
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
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I)i Cremation
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TOWN OF QUEENSUURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road. Queensbuiy. New York 120U4
Phone t513) Crematorium 745-4477 (if no answer)
Cemetery 745-4476
•. AUTI-IORIZATION 'I O CREMA I E
The undersigned requests and autimizes I'iiie View Ciematununi. in accuidance with and subject
to its Rules and Regulations to cremate the remains ul:
(NAME) (SE-A)
K)P&-4pJ6t- G"" (MC-Ul.
(STREET) (CITY) (STAI -) (ZIP CODE)
who died on day ufJ"l�tG�lf;u_ 20
at U k �iLo4 (7
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
�l14J A- e, ,6k- o
Relationship to deceaseCNU614-TE)2.
Name of Funeral Home � J (K& Lod JWeru�
IMPORTANT
I represent that to the best of my knowledge, (fie deceased has or has 110 pacemaker In his or.her
body. (CIRCLE ONE)
I certify that I have the full power and authorization to arrarlye for(lie 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 clalTor demands a re not w olly groundless, false or fraudulent.
(WITNESS) (ADDRESS)
67
(SIGNATURE OFtELATIVE OK LEGAL . AND ADDRESS)
Signed on this date: