Darrah, June ROAD,PINE Y(EW Q,u(E rz u
CEMETERY ,��
QV�.KP-R CREMATORIUMS
QVEPNSBURY
(518) 745.4-q76 �w YORK 1280q
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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
Jo/ e L�Q r�"�c l�
(Name) (Sex)
(Street) / (City) (State) (zip Code)
who died on �-' / /6, day of p, 20105Z
di
at C�/� f Q G�S ; /��1 t
(place) ( )
Name and address of nearest living relative or name of person authorizing cremation:
(Name) / / (Address)
Relationship to the deceased AlaS84 Il
Name of Funeral Home 6�6W,11 071
IMPORTANT:
I represent that to the best of my Ivwwl®dge,the deceased(has)or tea pacemaker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device In his or her body.(Circe One)
19990 that i and authorization to arrange for the cremation of the remains and to direct the disposition of the
ed re ins,that any I possessions have either been removed or may be destroyed,and agree to protect,defend and
e Pine View Crem um from any and all claims and demands for loss or damages which may be made against them
tiY r of or connected with tineremabon of said remains as directed,whether such claims or demands are or are not wholly
false or fraudu I
U
(VYdness)-__ (Address)
(Signature and Address of 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: �E7Z�.e� To �L/it/�� �- /✓4�ice.
If pulverization of cremated remains is requested,check here
Revision:April 18,2007