Fowler, Albert L O7V/ OF QUPINEEENSB
VIEW CEMETERY AND CRE
QV�R ROAD, QUEENSB MATORIU
URY� NEW YORK 12804
(518) 745.4476 (518) 745-4477
1 Funeral Director
Fame
ohJ[��r Date Of Crema t Case
ion Time Cremation Started
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Time Cremation Completed Ud �
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Remarks
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Town of Queensbury
Pine Vew Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office:(518)745-4475, 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: _
(Name) (Sex)
(Street) (City) (Stat (ZIp Code)
who died on day of__—� ro"J- 20 Q
at 4j a'T
( lace) (Address)
Name address of nearest living relative or name of emation:
(Name) (Address)
Relationship to the deceased W I -e-
Name of Funeral Home -Jtl 4J ( r1.
IMPORTANT:
I represerd dig to the[test of my Imowledge.the deceased(has) rho) aker,deflator or any other battery operated
device in his or her body. (Circle One)
I certify that I leave hull power and aUth0fiZ8ti0n 11D arrange for the cremation of the rernairis and to direct the disposition of the
cremated rer ivins,[het any personal possessiom have either been moved or may be destroyed,and agree to protect,defend and
save harmless Pine Mew Crematorium from any and all claims and demands for loss or damages which may be made against them
by reason afar eonneced with the cierrradon of said remains as direrked.whadw such clasps or demands are or are not wholly
groundless,false or hautde dnt.
►tiCt 1M o�1Ar 0, f�tt. �L.A--` //
.. (w (A ) -
Abiwass elbtive or Legal Representative) -- / QS 4�
Signed on this date: Y
J
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as foilovvs.
Mad to
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
Revision:January 1,2006