Spengler, William Jr. TOTV7� Off' U E 7J �/'
PCNE VIEW CE s� uT
METERY AND CREMATORIUM
QU'VX-ER ROAD, Ql1EENS5VRY, NEW YORK 17804
(518) 745•4476 (518) 745'•4477
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Cremation vs fi
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Te Cremation Scanted
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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 mahort=es Pine View Ownstork m,in a000rdatoe with and subject to Its Rules and Regulalorts to
cremate the remakts of
1J, a-I A �Jd2s,
(Name) (S c)
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(mi) (ChY) (fie) (Zo )
who died on day of 20�
at d s 9/-Iu- ( Awe-4-an-&a
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Name 7oa-777t:of neares �g or name a person astthorizing
7-
7(Name) ( )
Relationship to the deceased (is! Fv
Name of Funeral Home Fujlc
IMPORTANT: (��(
I represent that to ttte best of my WaMedge,the s)or no) ,battery.battery pack,power
call,radioactive krgfttt or radioactive device In his br
I certify that I have full pourer and athorbation to arrerW for the cranedw of the remains and to direct the disposition of the
cremated remains,that any personal possessiora have either been removed or may be destroyed,erd agree to protect,defertd and
save harmless Crematorium from any and all dellms and demands for loss or damages which may be made against them
by reason of or with the of said remains as ,whether such dalms or demands are or are not wholly
�otuxss,false
6-d � /�
( ) y
(signature and7-P310,
eletMe or ReP )
Signed on this date
Disposition of Cremated Remains
I hereby direct Pine View Cremelorko to dispose of the cremated remi fns as follows:
Mail to
Other arrartgemer"-Please spew.
If pulverization of cremated remair►s is requested,check here
Revision:April 18,2007