Moulton, Heather OF
QUEE�OUTO,
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745•-4477
t� I Funeral Director
Fame
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' ,- me Cremation Completed
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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 auftmes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the retrains of: h"Iv,—
(Name) (sex)
0 2 tJ ' ; /o ' U ' I I Z r 2e-d y
(Street) (City) (State) ( p )
who died 2 / S 7- day of '�` 20
at _ r ram.LS �J9?.tI:A�
(Place) (Address)
Name address f est living relative or of person cremation:
e) ress)
R to the deceased
Name of Funeral Home is�1 - � UrJ
IMPORTANT:
I represent big to the best of my knowledge,the deceased(has) (f�s no) er.de3briliator or any other battery operated
device in his or her body. (Circle One)
I certify that I have KA power and mrthorizabon to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,00 any Persond PAS have either been removed or may be destroyed,and agree to protect,defend and
save harmlepsPine Vow CremMmium ftm any and all claims and demands for loss or damages which may be made against them
by reason a' vAh crematian of said remains as died,whether such darns or demands are or are not mx0y
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(Signature and Address of Relative Or-UWW Representative)
Signed on this date:
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Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
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Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
Revision:January 1,2006
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