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Mortensen, George Yr vp 0-T QUEEN50UT PINE VIEW CEMETERY AND CREMATORIUM QUAKP-R ROAD, QVEENS5LRY KEW YORK 17804 (518) 745.4476 (518) 745'•4477 Funeral Director_ Cased �d '• e 4 � Cremation _ me Cremation Started . Te Cremation Completed —Pe of Container ( tif( ocircl f f 4 remarks M T C); 110 vv r io ' a� Ty 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: l .( QapfT ( �2 ( ) (Sex) 100 M�o-P-Ir detroc,r~ I:�y. 1 '28p3 (Street) (City) (State) (Zip Code) who died on 2( day of if 20 077) at uo its W I u (per) (Address) Name and address of nearest living relative or name of person authorizing cremation: (Name) (Address) Relationship to the deceased ` Owx Name of Funeral Home Lim IMPORTANT:I represent that to the best Of my Ivwwledge,the deceased(has)(C Anoymaker,defibrillator,battery,battery pack,power cell,radioactive implant or radioactive device in his or her body. 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 7rM7Tik-j-L ,tres ( ) , . (Signature Address of Relative or Legal Representative) Signed on this date: �-7 ©� Disposition of Cremated Remains I hereby direct Pine View Crematorium to dispose of the cremated remains as follows: Mail to Other arrangements-Please specify:TZETZt CZ� l C� EY IV If pulver nation of cremated remains is requested,chit&here— Revision:April 18,2007