Dombeck, Theresa OF l..l�L
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PINE VIEW CEMETtRy AND CREMATORIUM
QUAX?—R ROAD, QUEENSBURY, NENY YORK 12804
(518) 745.4476 (518) 745-4.477
Funeral Director A '�
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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 to its Rules and Regulations to
cremate the remains of: _
i9- l� . U o 6� l'� L
(Name) ( )
ties s -o c'O s--s � viz:: C� �
(Street) (City) (State) (ZIP Code)
who died on 2 day of L �. 20-0
(Place) (Address)
Name and address of near luring relative or name of person wing cremation:
M a n-as r r
(Name) (Address)
Relationship to the deceased
Name of Funeral Home 11'1C
V
IMPORTANT.
I represent that to the best of my knowledge,the deceased(has) (�no) er.defibrillator or any other battery operated
device in his or her body. (Circle One)
I certify that 1 have full pourer and a*mnzatiorn to mange for the cremation of the remains and to direct the disposition of the
cremated remains,out any personal possessions have either been removed or may be destroyed,and agree to protect,defend and
save harmless Pine view CremakNium fmm any and all dairns and demands for loss or damages which may be made against them
by reason of or with the cremagon of said remains as c ectK wIxW r such dairns or demands are or are not wholly
(groundless, or t.
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(Addreoo
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(Siignature and Address of Relative or Legal Representative)
Signed on this date: Z ` 13
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