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PINE DER' CEMET>rRY CREMATORIUM
Q� R R0,4D, QIJEENSBI,IRY, NEW YORK 12804
(S18) 745.4476 (518) 745'.4477
uneral 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 remains of: r/
GtrZ7er2 T �ade
(Name)
C \\
J 1 4; S 1-i r yn u e ( ►s e(Zip Code)
(Street) (Cty)
who died on vs� day of ,,,n c 20-.QZ
at ke i i
( ) ( ress)
Name and address of nearest living relative or name of person su ttorb*V cremation:
Li Gr
(Name) (Address)
Relationship to the deceased j u F
Name of Funeral Home n
IMPORTANT: the deceased(has) (has no Pacemaker,defibrillator,battery,battery pack,Power
I represent that to the hest of my Ivtowledge,
cell,radioactive implant or radioactive device in his or her body.(C' )
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 Cremat any and all claims and demands for loss or damages which may be made agatr>st them
by reason of or conned of said remains as directed,whetter such claims or demands are or are not wholly
ground t
' (Address)
(Signature and Address of Relative or Legal Representative)-
Signed on this date: f; Z
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 pulvertmtion of cremated remains is requested,check here
Revision:April 18,2007