Underwood, Shirley rrOcl4N OF QUEENs5BUPY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Di r ctor 13 K� ,
Name �J ` Case#
Date Of Cremation
Time Cremation Started
Time Cremation Completed
Type of Container A A ► (M
Remarks
G
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TOWN OF QUEENSBURY
• ` ` PINE VIEW CEMETERY
8
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:
(NA E) (SEX)
LR-
(STREET) (CITY) (STATE) (ZIP CODE)
who died on day of 20�
at? a
(PLACE) (ADDRESS) '—"—'—
Name and address of nearest living relative or name of person authorizing cre t1:
Relationship to deceased
Name of Funeral Homej?j 1�1�MC C F nPr�l NU rn
e
IMPORTANT
I represent that to the best of my knowledge, the deceased has or has n .pacemaker 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 personarpqM. ssions have.either boen
removed or may be destroyed, and agree to protect. defend and`sa ;' less Pine View
Crematorium from any and all claims and demands for loss or d8' ' s�ch may be made
against them by reason of or connected with the cremation of said relaii s directed, whether
such claims or demands are or are not wholly groundless, false or fraud
(WITNESS) (ADDRESS)AA
(SIGNATUR-ff OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date:/O - / 9-a
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