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Cottone, Frank
OF YI QUEE9�f�5�BUT PLNE �.J ER CEMETERY qNp QUR R CREMATORIUM On�, QljEENS"URy, NEW YORK 17804 (518) 745.4476 (518) 745'•4477 Funeral Director Fame L L [ rc,nF C .Hv1t Ca s e,ie Li4 =a e Of Cremation I-me Cremation Started 7 me Cremation Completed 10 .. v � rpe of Container, Remarks /kI T S"v o yr . q3--------------- v� 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 of: f4 kl/< C©7TU AJ E� (Name) Sex (Street) (City) (State) (Zip Code) who died on day of 8�k i/ 2007 at kz� GUlftL �5T IDi IVaM d N" (Place) (Address) Name and address of nearest living relative or name of pe7 authorizing oration: (Name) (Address) Relationship to the deceapwd Name of Funeral Home - IMPORTANT: I represent that to the best of my knowledge,the deceased(has) (has no) sker,defibrillator or arty 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 Crematorium from any and all claims and demands for loss or damages which may be made against them by reason of or connected with the cremation of said remains as directed,whether such claims or demands are or are not wholly groundless,false or fraudulent. (Witness) (��)p� ,1 Eck d (Signature and Address of Re ive o Legal Representative) i Signed on this date: L 3 • Z o0 Disposition of Cremated Remains I hereby direct Pine View Crematorium to dispose of the cremated remains as follows: Mail to Other arrangements-Please specify: 7V<70-dt� l � If pulverization of cremated remains is requested,check here ✓ Revision:January 1,2006