Sakser, Anne '7""0r4N OF QUEENB Try
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, Qi1EENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name A V1v?C Q .cQ - r- —J&—�
Case#
Date Of Cremation 0C �
Time Cremation Started
Time Cremation Completed r
Type of Container CR r J
Remarks
Sr
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 requa6IS and euttrorizas Pine View Crematorium,In accordance with and aMW to its Rubs and Regulations to
cremate the of•.
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(Name) (sex)
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ue
who died on dm4 Cq--
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Name address of nearest living or name of person authorizing cxemailon:
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(Name) (Address)Relationship to receased — V)Z
Name of Funeral Home ' U U t
IMPORTANT: theboocell,radloective�imptere or radioactive device In his body.gEi7s
of my kwwledge,Ow dec (has), o N aker, Y'battery Pik.Power
1 certify that I have full power and authortzatbn to arrange for the cremabon 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 hennless.pine View Crematorium from any and all claims and demands against the
for toss or damages which may be made against
by reason or with aametion of said remains as directed,whether such claims or demands are or are not wholly
�t Ov e
and Aditsss�of Relative or Legal Representable)
Sued on this date: /V�S1 a /
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 pulverization of cremated remains is requested,check here
Revision:April 18,2007