Porter, Mark 1J
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PCNE VIEW Qurzr B u
CEMETl~Ry ^Np CREMA-roRlum
QUNC]'R ROAD, QVEENSBVRY'
(518) 74S. NEW YORK 17804
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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 '
AU#KWiZatllon to Cremate
The undersigned requests and atphorizes Pine View Crematorium,in accordance with and subject to Its Rules and Regulations to
c ernate the remains of
�I Pr4c-,,- Mn le-
(Nam)
5 l SimGLP-77% by 1 q
(sbw) J (city) (StMe) (23p Code)
who died on day 0f AI AL 20.0(pP
at f2 k n,-- IT&I+,, i
(fie) )
Name and address of nearest living raiad a or name of person atrlhorQing cremation:
(Nam ) (Address)
Relationship to ate deceased
Name of Funeral Home
IMPORTANT:
I represent that to are hest of my knowledge,the deceased(�) (� ata�deftrMator,may. y PW.p�
cell,radioactive implant or radioeWve davios in his or her body.
1 anrtity do 1 have full power and atrt wftedon to arrange for the aemedon of the remains and to direct the disposkion of the
aemated remains,anal any personal possesslions have epher been removed or may be deMayed,and agree to"mi.defend and
save harmless Pine View C ramosorkm from any and all dams and demands for loss or damages which may be made against ahem
by reason of or connected with the cremation of said remains as dieded,whetm such clams or demands are or are not wholly
false or fraudulent.
(YVMrness (Address)
and Address of Relative or legal Represanta0m)
Signed on awls date: 71IL 1 0
Disposition of Cremated Remains
I hereby direct Pine View Ownatorknn to dispose of one aemeted remahs as follows:.
Mail to
other arrangements-Please specify: r
if ptAreriMmon of cremated remains is requested,dwxk here'_
Revision:April 18,2007