Cook, Jean Y
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QU E E
FINE VIER' CEMETERY QVEEN ,-I QV'`�CP3t ROAD, CREMATORIUM
SHURY, tKEW YORK 1280q(518) 745.4476 (518) 745'.4477
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 Regulations to
cremate the reins of: �^
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(Na ) / (Sex)
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(Street) U (City) r,—}— ( ate) (Zip Code`)'
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(Plac�) �� (Address)
Name and addrqss of 7rMi ,
relative or name of person author zing crema
AW D 1 v "UN-
(Name) ( '-
Relationship to the deceased i
Name of Funeral Nome 6 i
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IMPORTANT:
I represent that to the hest of my knowledge,the deceased(has) (has r
ji)pacemaker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her body.(C— )
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 possessions have either been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View Crematorium from arty 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 wholly
groundless,false or fraudulent.
(witness (Address)
(Sig u Address of t 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 spectly:
If pulverization of cremated remains is requested,check here
Revision:April 18,2007