Miller, Myles TOR��' OF QUEE9�5OUg�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY NEW YORK 12804
(518) 745-4476 (518) 745•-4477
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Funeral Director
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Case#
Date 0f Cremation � - _ G
Time Cremation Started
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)7454477
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:
Y-Y�L4j r s Y� �._�)
(Name) (Sex)
! 1 l i n,24 Ft .
(Street) Mty) » (State) (Zip Code)
who died onF`- day of )<)2 20 d 7
at YL7 YC> >LL7» C4
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
(Name) (Address)
Relationship to the deceased kZ5 7&
Name of Funeral Home
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has) has no) maker,defibrillator 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 C from any and all claims and demands for loss or damages which may be made against them
by reason of or conned the mation of said remains as directed,whether such claims or demands are or are not wholly
ground ule
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Address
to ( )
( ture a -Address a tive or Legal Representative)
Signed on this date: �-
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