Woodcock, Barbara TOT�N
A(,SB 2.1-rR,y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEFNSSURY, NEW YORK 12804
(518) 745-4476 (518) 745•-4477
Funeral Director
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Time Cremation Started
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Time Cremation Completed
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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 aulhonzes Pine view Crematorium,in accordance with and subject to its Rules and Regulations to
the remains of:
(NaR1e) (sex)
�.1 lti.)n �.�_ `r (city)nr� (ate) (zip cam)
(street) C�.7
who died on _ °f �'
at
(Place) (Adam)
and address of nearest wing relative or name of Person ahAthon&q fin:
u55c,1 l W ood�x _
( ) (
Relationship to the deceased_. h V,6 bfi1
Name of Funeral Home J wY T 1
IMPORTANT: the deceased(has)or no ,defibrillator or any other battery operated
I represent that:to the best of my Ivhowledge,
device in his or her body. (Circle One)
I certify that 1 have fun power and ral possessions
to hew ther been removed or mf the ay destroyed,is and to direct the disPOS;itlOn of the
�agree to protect,defend and
cremated less Pine
that any persorhel P �all claims and demands for loss or damages which may be made them
save harmless Pine View Crematorium from any
by reason of or connected with the cremation of said remains as domed,whether such dalms or demands are or are not wholly
Tess,false or fraudulent•
(Witness) (Address)
( Address of ReMw or Legal RewpeserttatNe)
Signed on this date: Z
Disposition of Cremated Remains
1 hereby direct Pepe View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:
If pulverization of cremated remains is mquested,check here --
Revision:January 1,2006