Horwath, George OF
PwE YIE
CEMETERY AND CREMATORIUM
QUAKER ROAD, 4UEENSHURY, NEW YORK 17804
(518) 745.4476 (518) 745'.4477
Funeral Director
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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 View Crematorium,in accordance with and subject to its Rules and Regulations to
crema7 remains of:
(Name) �\ (sex)
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(Street) (City) (fie) 4Z )
who died on 21 - day ofat -
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(Place) (Address)
Name address of nearest living relative or name of person audxxtting
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(Name) (Address)
Relationship to the deceased )
Name of Funeral Home IAY '` )1x +(J N(�
IMPORTANT: 'r~
I represent that to the best of my btowledge.the (has no) er.defbrNlatar or any other battery operated
device in his or her body. (Circle One) O� "1 O . ,lT-72--'V1 S
I certify that 1 have fuN power old authorization to arrange for lire cremation of the remains and to direct the disposition of the
cremated remains%brat any person possessions have either been rernoved or may be destroyed.and agree to Protect.defend and
save harmless Piirm view C enrt ADdL nt from any and al c lakrrs and demands for loss or damages which may be made against them
by reason bonnec:ted with the of said remains as deeded.whether such dab, or derrrands are or are not wholly
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(Signature and Address oIR e or Legal Representative)
Signed on this date: Z O
Disposition of Cremated Remains
I hereby direct Pine view Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:
if pulverization of cremated remains is requested.check here
Revision:January 1,2006