Payrett, Olga OF ���
2 NSBUPy
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSgURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Name
Funeral Director
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Case#. $�
Date Of Cremation ell
e fi 5-
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Time Cremation Started 7,20
Time Cremation Completed
Type of Container �,frLhr
Remarks
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Town of Queensbury
Pine Yew 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 fhe remains ct .
(Name) (Sex)
j �z y
(Street) ) ity) ) (Zip Code)
who died on / St- day of ���i 20
(piece) (Address)
Name and address of living relative or name of person authorizing
(Name) (Adder) �2. i1 C C- A)'T
Relationship to the deceased
Name of Funeral Home 'AJ(L "f
IMPORTANT:
i represent that to the best of my knowledge,the deceased(has) no) .defkbriilator,battery,bad pack,powercell,radioactive implant or radioactive device in his or her body.
I certify that I have full pourer and auttwrTzation to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,that any personal possessions have either boar removed or may be destroyed.and agree to protect,defend and
save harmless Pine view Caremaoorlurn from any and all daims and demands for loss or damages which may be made against them
by reason of or oorrAK"d with the cremation of said ins as directed.whadw such clalnns or demands are or are not wholly
oroundless_1alue or traudulanPn
/ I
(winless) ( )
00,
(Signature and or legal Representative)
Signed on this date: J G�L 0-)
Disposition of Cremated Remains
i hereby direct Pine View Crematorium to dispose of the cremated remains 89 follows:
Mail to
Other arrangements-Please sPedfy:
If puivert mton of cremated remains is requested,check here
Revision:April 18,2007