Johnson, Martha TO`74N OF QUEEN
,5 rB U To,
PINE VIES' CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745--4477
Funeral Director /�( a
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Date Of Cremation
Time Cremation Started
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Cremation Completed I
Type of Container
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Remarks
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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 authogK Fine View Crematorium,in accordance with and subject to Its Rules and Regulatkxs to
cremate the Ins
(Name)I` ) n
\1 mR • (Sax)
"I IL 1,
JJ�OdIII .Its NY ►�03
(meet) (City) (state) (ZJp Code)
who died on 21 day of Oe ern/1C r-
at
at_ CA :llS 1 l�Cc�t�rI l
(Place) (Address)
Name and address of nearest living relative or name of person authoitring cremation:
(Name) (� `(,Address) 11g� N`r' ( l 33 (e
Relationship to the deceased
Name of Funeral Home M, L _ k�lmr2r �.nP N�,rnP
IMPORTANT:
I represent
a that to
best of my knowledge,the deceased(has)or6�1
pacemaker,defibrillator or any other battery operated
body. (Circle One)
1 certify that I have fuU power and authortration 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 whk h may be made against them
by resew of or Connected with tM cremation of said remains as directed,whether such claims or demands are or are not wholly
groundless,false or fraudulent.
(Witness) (Address)
(SIginatbre hnd Addre elawe or egal Representative)
Signed on this date: 2 ' 22 7' d 6
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:
If pulverization of cremated remains Is requested,check here
Revision:January 1,2006