Greenwood, Kathryn Y
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PONE VIEW CEMETERY AND ��� ��
QUAKER ROAD, Q(jEL'NS6URY CREMATORIUM
(51 $) 745 4476 KPW YORK 128D4
(S18) 745..4.477
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URY, NFW YORK 12804
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Town of Queensbury
Pine View Cemeterj 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 Reguiatiojs to
crematp1he remains of: _
(Sex)
(Street) (City) (State) (Zip Code)
who died on day of JL 1 200 7
at rv{,.� � N�Ps ,-/P�f„y l�/g1� ll� y —
(Place) (Address)
Name and address C of nearestliving relative or name of person authorizing cremation: / /A. T E��rk 673/ )-A ye , _! A ` j3a-,4d1 a4,
(Name) (Address) ,
Relationship to the deceased 42"—a
Name of Funeral Home 1 r , r-k.-
IMPORTANT:
I represent that to the bast of my Ivtow{edge,the deceased(has)or( ads no) -pacernalcar, Iefibr'lator or any other battery operated
device In his or har body. (Circle One)
I cartify that I have full power and authorization to arrange for the cremaUon of the remains and to direct the disposition of the
cremated remains,that any personal possesslons 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 wt*b 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 wholty
grou leas, �lent,
(Address) / / vc-
1
nature and Addreifs of RWative or LegalRepresentative)
Signed on this date: �� 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:
If pulverization of cremated remains is requested,check here
Revision:January 1,2006