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PINE v1EW CEMET>rRY ,,ND �� u�
QUnxpR ROAD, CREMATORIUM
Q ENSBURY, NTW YORK 1'2804
(518) 74S•4�176 (Sl8) 745'•4-477
F'jneral Oirector
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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:
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(Name / sex) n Lis-
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(Street) A4 (C. ) (State) ia. )
who died on (� m day of
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(Place) (Address)
Name and address of nearest riving relative or name person aumorfiztng cremation:
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(Name) (Address)
Relationship to the deceased
Name of Funeral Home 4.
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her body.(Circle One)
I certify that I have ftA 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 eason of or ed with the crerpationipf said remains as directed,whether such claims or demands are or are riot w vity
ndiess,false ULard _ /4� P-') a
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(Witnessy (Address)
X# (SignafurqAnd Mdress of Relative or Legal Representative)
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify: ` r/tJ
If putveri action of cremated remains is requested,check here _
Revision:April 18,2007