Blethen, Harriet N E YI EW �
PO � LL
QU
CEMETERY �Kp CREMATORIUMS
� ��t ROAD,sC QIIBENSBt,�Y,
(518) 745,4476 NF-W YORK 178N
(S18) 745�4-477
Funeral Oirec ( or
a '. e �� Crematlon � • .
Te Crematlon Started ^..
_ 4 S
Cremation Completed
;e Of Con ( alner
eve 1Z �rS
♦ � I V
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
crem to the remains oF. p
�_.cx��1/lQ o— 'J-P-/VK11 Q-2__—
ame) (Sex)
dh),� - LftqAA J" 168,01
(Street) (CRY) ) (State) (Zip Code)
who ied on �I day of V 20 2
PrK dti 1o�c�U�
at
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
YS%y�C l cir�s�7
(Name) (Address)
Relationship to the
Name of Funeral Home 7
IMPORTANT:
I represent that to the hest of my WxwAedge,the deceased(has)iAia
maker,defibrillator,battery,battery pack,power
oaccell,radioactive Implant or raditive device in his or her body.
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 possessK=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 with the cremation of said remains as directed,whether such claims or demands are or are root wholly
7,less,false
W ) (Address)
D�
ignaturee and Address of Rela N egal Representative)-
Signed on this date: /- I8-6 q
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 pulverization of cremated remains is requested,check here�—
Revision:April 18,2007