Borner, Anna �OrV1�� OF l..l��
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PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QVEBNSBIJRY, NEW YORK 17804
(518) 745.4-476 (518) 745'.4477
Funeral Director
Fame
Case#
mate Of Cremation
me Cremation Started
. . me Cremation Completed L'I qU
, ype of Container
Remarks
3'� I
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 subject to its Rules and Regulations to
cremate the remains _
(Name) (Sex)
Ll
(Street) (City) tqmq ip Code)
who died on day of /F2� / r 20t�?
at _ LC-� P — (V L' 1 Z f 6 l
(Place) (Address)
Name address of nearest living relative or name of person aut 'ng creme .
5 e;--
(Name) V (Address)
Relationship to the deceased -1
Name of Funeral Home
IMPORTANT:
I represent that to the best of my Wxiwledge,the deceased(has)or no) aker,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 P' View Crematorium from any and all claim es s and demands for loss or damages which may be made against them
by reason ' connected with the cremation of said remains as directed,whether such claims or demands are or are not wholly
groundless,far qr fraudu t.
��) (Address
(Signature and Addr qs off Relative orl resen rve)
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