Fennell, William 097
PWE QUEE9�(.50Ur�y
VIEW CEMETERY AND CREMATORIUM
QUA-y-F-R ROAD, QVEFNS8URY, NEW YORK 12804
(518) 745.4476 (518) 745'.4477
Funeral Director
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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) 745-4477
Authorization to Cremate
The undersigned requests and authorizes Pine Viaw Crematorium,in accordance wdh and subject to Its Rules and Regulations to
cremate the remains of:
!✓' (SOX)
(Name) ff /�
E✓t 77P. /7VC-• / �(S �S �(ZlpCode�)
(Street) � (City)
who died on �
S day Of zo0'7
at iS /eS�ofehC
(Place) (Address)
Name and address of nearest living relative or name /person authorizing cremation,
'r (Address)
(Name) / �.57��
Relationship to tho deceased l
lly
pK �
Name of Funeral Home
ifs -��6;_n � .
IMPORTANT: the dece (has) (has no)pacemaker,dalibfillator or ahy other battery operated
1 represent that to the best of my knowledge.
device In his or her body. (Circle One)
I certify that I have full power and authorlzation to arrange for the cremation of the remains and!a direct lice disposition of thend rid
cremated remains.that any Pa rsonal possessionsand al!d Ims and demands a loss or damages which may be have either boon removed or may be destroyed,and agree to made aga frost them
save hamtloss Pine View Crematorium►from any
whether S claims or demands are or are not who
by rea.on of or connected with the cremation of said remains as directed,
gro�a tsl:e fraudUle - �-;�
(Witness) ddress) �
(Signature and ddress of Relative or L al Representative)
Sloned on this date'
Dlsposilion of Cremated Remains
l hereby direct pine View Crematorium to dispose of the cremated remains as follows'
Mail to-
Other arrangements-('lease specify.
if pulverization of cremated remains is requested,check here
Revision:January 1,2006