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PONE VIEW Qur �9�.5 2
CEMETERY Airy
QUR RO�p, Qvr_t'NSetlRY CREMATORIUM
(5) 8) 745,4476 (51KEW PORK 128t)q
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FQner8 Director
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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:
cremate the remains of bfea to its Rules and Regulations to
S- (sex)
(Street) (Cm,)
(State) (Zip Code)
who died on day of 4 20
ate
Tess)
Na and address of nearest living relative or name of person authorizi
ng ng cremation:
Co
(Na C `�
me) Cfl F, (U
(mess)
Relationship to the deceased S,
Name of Funeral Home
IMPORTANT:
I represent that to t�Of my C��{ the (has) ( no) maker,defibrillator or battery operated
device in his or her ) any other
1 certify that 1 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
by reason of•kx connected with the cremation of said remains as directed, claims or demands
may be made against them
9r odless, udulant. such claims or demands are or are not wholly
(witness (IV
r ) (Address)
77(
( Ig azure and Address of elative or Legal Representative)
Signed on this date:
Disposition of Cremated Remains
1 hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other 8rtengements-Please specify:
If pulverization of cremated remains is requested,check here
Revision:January 1,2006