Deyoe, Leafy TOWA� OF
P QUEEN 50Ury
WE VIEW CEMETERY AND 1'V
QUAKER ROAD CREMATORIUM
QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745*-4477
Funeral Director
Name q{ cif
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Case# +�(�
Date 01 Cremation
Time Cremation Started la ,36
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Time Cremation Completed
Type of Container
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Remarks DNS^
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12804
Cemetery Office: (518) 745-4476, Crematorium: (518) 745-4477
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
( (Sex)
-I ( � C17
(Street) (City) (State) (Zip Code)
who died on ' g day of 2006
at
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
y
C—
(Name)
(Address)
Relationship to the deceased C A- `'. ✓4
Name of Funeral Home .d4 c s�, L 1 a e e Q /40 r 7-
IMPORTANT: _
I represent that to the hest of my WxWedge,the deceased(has) has no)pacemaker fibrillator or any other battery operated
device In his or her body. (Circle One)
I certify that I have 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 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 wholly
groundless,fa or lent. J y
(Witness) (Address
G✓liLcz 46a,
(Signature a Address of Relative or Legal Representativey
Signed on this date: L-6
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as fdlows:
Mail to
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
Revision:January 1,2006