Smith, Cynthia rY�V (`—c L L
PINE ti/IEW CEMETERY *,ND U�
QUA.XeR ROAD, QUEMN,,, CREMATORIUM
(518) 745,4476 �Y' KEW YORK 128N
(518) 745.,4477
Funeral Olrectr
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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
cremat the remains of: A
( e) Sex)
(Street) (City) (State) (Zip Code)
who died 1 S day of 20�
at "�
(Place) ( )
Na and of nearest Iry relative or name of person authorizing cremes'
- / WO
(Name) (_���
Relationship to the deceased /
Name of Funeral Home 7 i
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has) (has no�pjcemak defibrillator or any other battery operated
device in his or her body. (Circle 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 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 connected wo,
the cremation of said remains as directed,whether such claims or demands are or are not wholly
grounoess false or fraudu
�-
- (Address)
4— ,rz�
(Sib
mtoKabd Address f Relative or Legal Representative)
Signed on this date: 0.7
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify: �Q jo ✓1
If pulverization of cremated remains is requested,check here _
Revision:January 1,2006