Knapp, Bernice �O O
F QUEEN,5BU9�yPINE VIEW CEMETERY
QUAKER ROAD, AND CREMATORIUM
QUEEIVSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
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Funeral Director �
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Date Of Cremation Case#
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Time Cremation Started
Time Cremation Completed (U;�(�
Type of Container Z�r lvd
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) 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 remains of:
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(Name) (sex)
(Street) (City) (State) (Zip Code)
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who died on Clay of 20 d 7
S 1 L�
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
(Name) (Address)
Relationship to the deceased
Name of Funeral Home
IMPORTANT:
I represent that to the best of my I xm6dge,the deceased(has) has no)pacemak defibrillator or any other battery operated
device in his or her 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 possessions 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 fox 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 whoity
groundless, or lent.
62�
(yyftness (Address)
(Signature d Ar IdreWbf lot lative or Legal Repr tative) / .. -.. . . ..-_..__-_..._
Signed on this date: eC
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:
If puNerization of cremated remains is requested,check here
Revision:January 1,2006