Beattie, Sandra . r
TOr N OF
QUEEN,sDUrp
PINE VIEW CEMETERY q \.J
QUAKER ROAD � CREMATORIUM
' QUEENSBURY, NEW YORK 128D4
(518) 745-4476 (518) 745*-4477
Name
Funeral Director
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Case#. _ �GL
Date Of Cremation AAff
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Time Cremation Started
Time Cremation Completed
Type of Container
c1rc iF ISL L'
Remarks '
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, Now York, 12804
Cemetery Office: (518)745-4476,Crematorium: (518)745-4477
Authorization to Cremate
The undersigned FaWftft eruct authorizes Pine View Crematorium,in a000rdwm with and subject to its Rules and Regulations to
cremate thopmains of: .
(Name) (Sex) —
( ) N (City) Cj ( ) (zip Codel
who died on 7 `� -of 20L G
(Place) (Address)
Hama end address of nearest living relative or name of persort
(mi) (Address)
Relationship to the deceased Q
Name of Funeral Homes? �t
IMPORTANT:
I represent that to the best of my ioowledge,the deceased(has) ls
no sitar,defibrillator.battery.battery peck,power
cell,radioactive implant or radioactive device in his or her body.(Cirde )
I ce*that 1 have 1#A power and authorization to arrange for the aentetion 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 harness Pine View C remeSorium from arry and all deims 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
groundless,false or fraudulent.
3uV
(Witness) (Addrn3ss>
'12
All Y
(Signetwe and Address of Relative or Legal Representative)
Signed on this darts: ! 12,V/(3
Disposition d Crametsd 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