Kenyon, Cleon 0 T (zu rz rE 9��5 23 U T
PINE SEW CEMET>rRy ^� CREMATORIUM
QNE "7t �.D, Q(jEEN3j5URy,
(S18) 74S•4.g76 ��''� YORK 12804
(518) 745'.4.477
J funeral Director
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Towne of Queentsbtrry
Pine View Cemetery and Crematorium
21 Quaker Road,QueensWry.New York, 12804
Cemetery Office-.(518)745-4476,Crematorium:(518)745-4477
Authorization to Cremate
The tmdersigned requests andaLtorizesPine view Via.in aeooedance with and su4ed to its Was,and Reglations to
cremate th7eirnam cf:
(Name)
. .� .64UI / 2,,P
a4a--7—
) (ZIP
(ekY)
who died on ` -- — day of r. `S G 2oQ7
at aQ
(Mace)
Name end adder of nearest WaV rek*ve or new of paraort authorising txernat"L
V e 1 u. 1/
r A( �12.V.A
CNfei�i it'tNyo>U ,,�FS� G�K(Address)erf 2d=-�IO
(Nam)
Relationship to the deceased
Name of Funeral Horne rL) a G '
IMPORTANT: OPMAW
1 represent that 10
tha hest of any kWwladga.the deoaased(tree)or gm no) •delft0 for or any other bWAMY
devtoe in t$a or her body. (Ciede One)
1 certify Bret I taeve tun power and auNroriaalion to gmw4le fior ueWbrsan the ranaairrs and in direct the disposiiorr of the
caaerrelad rgrr dW%anal aeny p poeiDeedorrs here ail W teeare raaeored or Wray be dashgled.and alb b protect.diatartd and
reason of ar awrrec7ed wihUreasne6on MFId id rerWei+s drectecl. sucd deice or detrrsr�are ar Wee y
or
(Addrg�)
( of Fh*M a or Legal Refxesenta
Signed on daW b
this '
plsposAM of Cremated Rem
1 hereby dined Plhe View Crgrnetolium to dispose of the cagoreted rettoins'as fd
Mail to
Other arranwMents-Please spew-
If pulverization of cremated mein is MWOSISd.cheek here
Revision:Jar my 1.2006