Whitacre, Evan (7"'n rp�,� OF QUEE9�-
PINE VTE CEMETERY AND ""QUAY-MR
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QUR ROAD, QUBpNSHURY, M
CR CREMPORK 12ATORIU
(518) 745.4476 ( 804
518) 745'•44477
_ I Funeral Director V
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
-4477
Cemetery Office: (518)745-4476, Crematorium: (518)745
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: I, I
lyl
(Name) (Sex)
C coon l 0-. d 0 y
(Street) (City) c� (State) (Zip Code)
who died on ) ' day of_ X 20DJ
(Place) OxIdress)
Fa W
Name and address of nearest living relative or name of person authorizing cremation:
nn��er M�f�Vler- 10 LaneLk- Ceor 7 i t 12�y5
(Name) (Addr }
Relationship to the deceased
Name of Funeral Home FU
I
IMPORTANT:
I represent that to the best of my kowledge.the deceased(has)or(has no)pacemaker•deRu lator or any other batiery 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 potions;have either bow removed or may be desir'oyed.and agree to protect,defend and
save harmless Pere View Cnwmk rium from any and all claims and demands for loss or damages vrhich may be roads against them
by reason oforconnectedvAh the cn wiation of said ranueins as drrecled,whaltier such c lairrrs or demands are or are not wholly
groundless,false or fraudulent.
(Address)
(Sig a and Address of Relative or legal Representative)
Signed on this date:
I
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Man to j
I
I
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
Revision:January 1,2006
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