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PINE DER' CEMETERY AND CREMATORIUM
Q�nsC-pit ROAD, QVF-ENSBURY, NEW YORK 12504
(518) 745.4476 (518) 745'•4.477
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 Regutatbns to
cr te the remains a
(Name) /n� I (Sex) A,
(Street) ( tty) ^` (State) (zip Code)
who died on 1 6 day a � Zo
at O<r 1. tf
(Place) U ( )
Name nd address11of nearest living relative or name of person t '^^au ng cremation:
(Name) (Address)
Relationship to the deceased Gc
Name of Funeral Home
IMPORTANT:
I represent that to the best of my Ivhowiedge,the (has) (has no)pacemaker,defibriliato(or any other battery operated
device In his or her body. (Clircie 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 possessi"have etcher 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 whotty
Witness) ( ess)
(Signatur ress of eiative or Legal R tativ
Signed on this date: 1A n e
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as foik)ws:
Mail to
Other arrangements-Please specify:
If putvertration of cremated remains is requested,check here
Revision:January 1,2006