Winslow, Annabelle OFQUEEN,.,5BUP,,_y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
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Name L
Funeral Director
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�sosl�y Case# 3(,2
Date Of Cremation
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Time Cremation Started
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Time Cremation Completed 10: 15
Type of Container q,
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Remarks
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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)7454477
AutlIorizalion to Cremate
The undersigned requests and aenhortws Pkee View fin,in accordance with and subject to ks Reies and Regu*ions to
rlfernei ls'of:
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( ) (Sex)
S 3 "`{ e' Nat,
(SW") (Cky) (State) (ZIP CA)*
who load on ' day,of 20-!�j
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and of nearest living relative or name of person authorizing cremation:
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(Name) (Address)
Relationship to the deceased
Name of Funeral Hornet
IMPORTANT:
I represent that to the best of my knowledge,the (tree) (het no)pacemaker,ddlbrilletor battery,battery peck,power
cep,radioactive ieeplari or radioactive device in tie a her One)
I cedly that 1 have U power and atSwriandon to arrange for the cremation of the remakes and to direct the dksposftn of the
cremeied remakes,that any I:A Q, a possessions hm either been removed or may be destroyed,and agree to protect,defend and
save hennless Pine View Crenrelorium from any and all claims and demands fior loss or ", o gas which maybe made agakest them
by reason of or connected with the cremalion of said renew as directed,whether such clakres or demands are or are not wholly
grouxndless,false or fraudulent.
(Witness)
( of Relative or Legal Representative)
Signed on this dais:z
Disposilion of Cremated Remains
I hereby direct Pine View C errretorhnn m dispose of the crerneted remei ns as follows:
Map to
Other arrangemernts-Please specify
If p Averization of cremated remains is r equ ,check here
Revision:April 18,2007