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(518) 745•4476 KMW YORK 12804
(Sl8) 745.4-q77
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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
(Name) , �� � (Sex)
3og
(Street) ( ity) (State) (Zip Code)
who died on dey of 20
f at O t lV/
(Place) (Addr ) � �
Name and address of nearest Irving relative or name of person authorizing Cremation:
(Ina Inc, 3o d
Cj(Name) (Address)
Relationship to the deceased O
Name of Funeral Home
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,defibrillator,battery,battery pack,power
cell, radioactive implant or radioactive device in his or her body.(Circle One)
I cervfy 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 Crematorium from any and all claims and demands for loss or damages which may be made against them
by reason of or ed with the il5rernalpn of said rern iris a�djr�cte�, claims or demands are or are not wholly
ndless,tar or ud�ent. �? tb JC�J—`1
o A
(w ( )
at r a /o elative or Legal Representative)
S+gned on this date: u 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 pulvertzation of cremated remains is requested,check here
Revision:April 18,2007