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Valenti, Maryann Y r7—O O 1 Qu rE T PLNE YEW CEMETIray "'N� �� u � QV`�CER ROAD, QUL'>'NS8 CREMATORIUM (518) 745.4476 U 'Y, NEW YORK 12804 (518) 745,4.477 rtrt Funeral Oicectoc (�d .Te ``f� V, �e Cof remation Started ^� CYemetlon Completed 'Z ;e Of Container l < eT.a , ,xs 2v\ i i -30 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 ql�' (Na ) (Sex) bA cL ue tg)0 yg `/ 1�&q- (street) J� (CRY) ' (State) (Zip Code) who died on ' "10Jvl day of JUL 20_i14— at b 6o NOVlt 1 CL�( d V (.(ee � frGl j� X� (Place) , (Address) Name and address of nearest living relative or name+ � (r2�'( 1'1r_ka4a y�dt��l�( CofD 1� (Name) (fir ) Relationship to the ii Name of Funeral Home I IMPORTANT: no er,defibrillator,battery,battery pads,power I represent that to the best of my knowledge,the deceased(has) cell,radioactive implant or radioactive device In his or her body.(C• I certify that I have fuU 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 with the cremation of said remains as directed,whether such claims or demands are or are not wholly groundless,false (yy )4LZ ( ) (S nature and Address of Relative or Legal Representative)- Signed on this date: 1 6� Disposition of Cremated Remains I hereby direct Pine View Crematorium to dispose of the cremated remains as follows: Mail to Other arrangements-Please specify: �'�`l �Q �kdL?n If pulverization of cremated remains is requested,check here Revision:April 18,2007