Robertson, Sara r,
TOW7� Off- QU rE E
PCNE 9 r-B
Y(EW CEM �
PR �ETERY AND CREMATORIUM ROAD, Q(�ENSBI RY, NEW YORK 12504
(518) 745.4476 (Sl8) 745'.4477
Fvneral Director
pp II � r yr 11�Fame �1oh r'isv r•' �- .
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PLNE Y(EW CEME �
TERM AND CREMATORIUM
XER ROAD, 4(jEF.IdS5URY, NEW YORK 12804
(518) 745.4476 (518) 745.4477
F,jneral Director I
a ' e or Cremation � �)
—e Cremation Starced
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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 aocordanoe with and subject to its Rules and Regulations to
cremate the remains of:
(Name) (Sex) \\
30 tree»cbt_rry
(Street) (City) (State) (Zip Code) /
who died on 22 day of ) u c 20 U7
at r::,�E722S l4a5,4;� J
(Piece) ( )
Name and address of nearest living relative or name of person authorizing cremation:
(Name) (Address)
Relationship to the deceased �'�cs�1111,121
f
Name of Funeral Home l
IMPORTANT:
I represent that to the best of my lme,the deceased(has) (has no) maker.defibrillator,battery,battery pads,power
owledg
cell,radioactive implant or radioactive device in his or her body.(
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 Crematorup from any and all claims and demands for loss or damages which may be made against them
by reason of or con ed tion of said remains as directed,whether such claims or demands are or are not wholly
groundless, or
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(Signature and Address 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
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Other arrangements-Please specify:
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If pulverization of cremated remains is requested,check here
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Revision:April 18,2007
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