Krzysik, Robin PINE YTEW
CEMETERY AND CREMATORIUM
QUA.KP3t ROAD, QUEENSBURY ?,CEW YORK 12604
(518) 745.4-476 (518) 745'•4477
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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 remains of:
ame) ( )
Ott AL L'b"" =n /D64
(fit) I (City) 0 (fie) Rip Code)
who died on 1 day of N AL/ 20 o-7
(Place) I (Address)
Name and address of nearest living relative or name of person atdhortzkhg cremation:
(Name) L&AL
(Address)
Relationship to the deceased
Name of Funeral Home rtxA jA r 1. �Ql J-KMjLj thA-Q-,
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)q' paoemaker,defibrillator,battery,battery pads,power
cell,radioactive implant or radioactive device in his or her body.(C e��ne)
I certify that I have fuU 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 cairns 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 riot wholly
groundless,false or fraudulent.
(V11dness (Address)
(Signature and A4401bss of R-elative or Legal Representative)-
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please spedfy: 4 tk,
If pulverization of cremated remains is requested,check here
Revision:April 18,2007