Bohringer, Karl P LN E Y(E W r� i �J
CEMETFN ,��
V CREM^TORiUM
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Q '�—"� ROnD, QIIEFNSBURY, KEW YOR}C 12804
(SI8) 7as (518) 745'•4-477
Funeral Director
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Town of Queensbury
Pine View Cemetery and Chem wdum
21 Quaker Road.Quemabury.New York. VWX
Cemetery office:(518)7454476,Crematorium:(518)7454477
Authorization to Cremate
The undersigned requests and authorizes Pine View Crematorium,in accordance with and mood to its Rules and Regstions to
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the remains of:
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(Name)
(Street) (Cky) (Sty) code)
who died on l ICA day of —209i�
at I (Place) (Address)
Name and address of nearest Wing relative Or-MI of person authoriz v cremation:
O t
I (Address)
L
Relationship to the deceased )t k -
Name of Funeral Home
IMPORTANT: .may,rY pod'.Per
I represent that to the best of my Wwwledge,the deceased(tree)or(has no)pOBf
cep,radioactive implant or mdkxm:tJ a device In his or her body-(Cirde One)
I cw*that I have U power and author UdW to arrange for the c emotion of the reme is and to dined the disposition of the
aerated remains,that goy personal possessions have either been rammed or may be destroyed,and agree to protect.defend and
save harmless nd so claimsand demands tr loss ordemaginwhich a"be meft against them
WVeson of or connected with the cremationsaid retain as directed,whether such claims or demarWs are or are not wholly
tales or fraudulent.
(VNitrress) - ( )
( and A[d�dress of R or Legal Rapoesermtive)
Signed on this date- 7� —
D*xxftm of O+ nsted Remains
I hereby dined Pine View ammtorium to dispose of the crarnsted remains as follows:
Mail to
Other artangemeris-Please specify-
If puiverkation of cremated remains is requested,cha*here
Revision:April 18,2007