Neve, Claire r.
TO O_TUE L�
PLNE VIEW CEM � ���8 ��
ETERY ANC CREMATORTUM
QU R ROAD, QV-EFNSBURY, NEW YORK 17804
(S18) 745.4476 (518) 745'.4477
iu neral Director J
i ..yin �L+v v TIQC j
1e�c Crier
`ace of Cremation
Te Cremation Started 7: A
^� Cremation Completed
;e o ! Container
a�
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
cr to the remains of:
M7 ok- Neve.
sex
(Street) - (City) tate) (Zip Code)
who died on \ l day of�_ 20
at�V�?l`yl +� �Y C.•
(Piece) (Address)
and address of nearest living relative or name of persona cremation:
(Name) (Address)
6S..
Relationship to the deceased I�
Name of Funeral HomecA n4e,
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has) has no) maker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device In his or her body.(C
I cartify that I have full power and authorization to arrange for the cremation of the remains and to direct the disposition of the
ba
,fa
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 for 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 wholly
gro false or fraudulent. .�
( )
(Signature and Address of Relative or Legal Representative)
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specfyl?v--��—' k)
If pulverization of cremated remains is requested,check here_
Revision:April 18,2007