Rzeznik, Priscilla h
TOrWJV, OF QUEE5V
P W E 53 �"� '` �/VIEW CEMETERY AND CREMATORIUM
QUAX-ER ROAD, QUEBNSBV-Ry, NEW YORK 128o4
(518) 745.4476 (518) 745'•4.477
Funeral Director I )('"smv
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Case# 15-
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbuy, New York, 12804
Cemetery Office: (518) 745-4476, Crematorium: (518) 745-4477
Authorization to Cremate
The undersigned requests and authorizes Pine View Crematorium,in
ato the remains of: accordance with and subject to its Rules and Regulations to
n: �>r;:Ilq A. e N�
(Name) (sex)
LA, N 7
(Street (City) (Stat e) (Zip Code)
who died on day of 11
at 17
(place) ress)
Name and address of nearest living relative or name of person authorizing cremation:
S Merry l� �CAIA4 � `f ✓~9w11 54 �r mod,
(Address)
Relationship to the deceased
Name of Funeral Home
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)oF(has no)pacemna&,defibrillator or any other battery operated
device in his or her body. (Circle One)
I certify that 1 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 dernands 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
gr nd haudu
ZO
c (Wftr>es�) (Address)
t )-LL,_ t CJ r -jam i 1 ,
(Signature and Address of Aelative oar Legal Representative)
Signed on this date: T- /O
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as fellows:
Mail to
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
Revision:January 1,2006