Cornell, Howard P LN E VIEW C E M �ETERY AND CREMATORIUM
QUA-X-EA ROAD, QUEENSHIIRY, NEW YORK 126N
(518) 745.4476 (518) 745.4-477
Funeral Director IF
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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 a thm ms Pine View Cremaodum,In aaordenoe with and subject to Its Rules and RegulMions to
cxernate the tertekns of
/J7al w k7K�JJ �, (.A►1n1�`L L ,�.d LL
{tVame) Seex)
/ cl �' ►aw /U l2�
(sue) (CRY) ) (ZO Code)
who died on Z I deg►of J ' I- __2007
at d
cam) c
Name and address of �reldve or raw of .
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(KUM) cam)
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ReleliorraW to the deceased w i /U-
Name of Frxterai Horne _-
IMPMAW:
i represent that to the Crest(*my lanowiedge,the deceased(free) (free no) rraiaar,defrillso or any othery open
d bo device in his or her dy. (C ft*One)
1 certify Chet 1 heve full power and autlw Uslion to arrange tow the crerrodw of the remains 0-4 to direct the disposition of the
crerrreted remains,that any personal possesWris have either been removed ow may be destroyed.and agree to prarteat,defend and
save Itarntlesa Ptrte View C'.reimeAorkrnt Unrrt any and all cleirrra arrf darrtertrls for toes a damages which may be made against them
by reesorr of the aenration of said remains ae dtrecW.whdher such claims or derraxtdo are or are not whey
—Z� f� _ ���� C�)�
(vNltrrerss (Afton)
(�
(SWOurb and Address of or Legal Rep"eram")
signed on this date: 2i lit d
Disposition of Owneled Rerrreirrs
I hereby direct Pine Mew Llwnstorrlum to dispose of the c onded rerrta lm as Mows:
Mall to
other anarrgernterds-Plesse specify:
if pc,ivertzebw of cremated remains is requested.ottedc here
Revision:.lammy 1,2006