Welch, Shirley OF QUEEr\�50U,?,,
PINEE VIEW CEM ETERY AND CREMATORIUM
QUAKER ROAD, Q(jEENS9URY, NEW YORK 12804
(518) 745.4-476 (518) 745'.44477
Funeral Director
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbuy, 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:
j-• e ��. l e_.
(Naf T1e) (sex)
(Street) (City) (State) (Zip Code)
who died on
- day of_ �- 2067
at
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
(Name) (Address)
Relationship to the deceased «� c
Name of Funeral Home <0—' A, tev. /-4,
IMPORTANT:
I represent that to the best of my ivtow{edge,the deceased(has) no) defibrillator or any other battery operated
device in his or her body. (Circa 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 Rossessi"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 wholiy
round fS lent,
Witness) I
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(Signature and Address of Relative or L al Representative) T
Signed on this date: a co
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Disposition of Cremated Remains
I hereby direct Pine View Crsmatorium 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