Petterson, Allen TO Off" ou��� BUT1Y
PINE VIEVY CEMETERY AND CREMATORIUM
QU.A.KER ROAD, QUEENSBURY. NEW YORK 12804
(518) 745-4476 (518) 745.4477
Funeral Director �'�- tik- Al
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TOWN OF QUEENSBURY r `
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury. 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:
� ZLl fF, /r S'efP yu
(NAME) (SEX)
(STRE ) (CI (STATE) (ZIP CODE)
who died on Il Q day of
20
at r� L S 1`71 0 5 / /.� Z- 0
(PLACE)
(ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Relationship to deceased AJ-z-4
i
Name of Funeral Home_ J14 LS f<
IMPORTANT
I represent that to the best of my knowledge, the deceased has or as no 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 w ' _may be made
against them by reason of or connected with the cremation of said remTirected, whether
such claims or demands are or are not wholly groundless, false or frau
(WITNESS) (ADDRESS)
(SIGNATURE OF RELATIVE OR LEGAL REP. AN DDRESS)
Signed on this date: