Asselin, Thomas Yr
OF QUEEN'5�BUT
PLNE VIEW CEMETERY AKD CREMATORIUM
QU&X-F-R ROAD, QUEENS5URY 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
cremate the rreem-ains of: 11
,- A'G-t
(Name) ( )
(Street) ) (City) (State) ( Code)
who died on day of_ 20 a
at SL�v1. f
-- (Place) (Address)
Name and address of nearest living 9�tatiive or name of person
_ 3 67S"1C" A-
(Name) (Address)
Relationship to the deceased
Name of Funeral Home FUJ Z
IMPORTANT:
I represent that to the best of my knowledge.the deceased(has) (has tto) aker,deflator or any other battery operated
device in his or her body. (Circle One)
1 certify that I have ful power and authorization to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,ittat any personal possessions have either been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View C rernalaiun from any and al As' i and don for loss or damages wlrch may be made against them
by of or connected with cremation of said remains as directed,whew such darns or demands are or are not wholly
grM7 'C—' ' C�)f
(Witness)
(Address)
(Signature and Address=orRelative resentative)
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Marl to
Other arrangements-Please specify:
if pulverization of cremated remains is requested,check here
Revision:January 1,2006