Jenkins, Mary (ZU E E 9��5 T U Try
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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 undersigrned requests and authorizes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of: y— ,/ _
A ry rrA A)C-es y1 Z rJ i��N_g 1-e- y�-►x+ l e�
( me) -ram (sex)
(Street) ) (City) (State) (Zip Code)
who died on 1 �� day of o ( 20 Q
at 30 rNr,4T,u,) 7
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
L,jA Jle,r oZl Zrisb T iw
(Name) W7)
Relationship to the deceased /
Name of Funeral Home &I it re)ZJe r e
IMPORTANT:
1 represent that to the best of my knowledge,the deceased(has) (has no pacemaker,defibrillator or any other battery operated
device in his or her body. (Circle One)
I certify that I have full power and author¢ation 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 ha Vie
w ew Crematorium from any and all claims and demands for loss or damages which may be made against them
by orconnected with the cremation of said remains as directed,whether such claims or demands are or are not wholly
gnwrtd o r MA, C
(Address)
( elattve or legal Representative)
Signed on this date: — — «
Disposition of Cremated Remains
I hereby direct Pine View Cremat to dispose of the cremated remains as follows:
Mail to �.� I it V /
Other arrangements-Please specify:
If pulver¢ation of crested remains is requested,check here_
Revision:July 7,2004