Kotrady, Rita Y
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PONE �qEW CEMETERY Q ENSBtRY NEW YORK 12804
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QU^X�R ROAD, CREMATORIUM
(518) 745 4476 (518) 745.4g77
`` Funeral Director
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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 Regutatans to
cremate the remains of
(Name) (Sex)
(Street) ity) (State) (Zip Code)
who died on
day of ( _20 07
'
at
(Place) (Address)
Name and address of nearest living relative or name of person authoring cremation:
f, o� t a 4-c ,-✓— f,4� r_ s
(Name) (Address)
Relationship to the deceased --
Name of Funeral Home e�e,V\ M v t e n e rk c-
IMPORTANT: ��
I represent thatt�hest of my knowledge,the deceased(has) (has no)pacemaker,defibrillator or any ocher battery operated
body. (Circle One) _�
I certify that I have full power and authorization to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,that any personal possesslom 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 wtolty
r fraudulent.
S a,,^ ✓C Coe: �1 IV j )521
(Address)
lure nd Addr o Re a or Legal Re—pre tative)
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:
It pulvertzation of cremated remains Is requested,check here
Revision:January t,2006