Rivers, Muriel TOrNN OF
QUEE9�5BUPy
PINE 'VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUHENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745*-4477
Name un it
Funeral Director�Mi3
�"t ' R'vers Case#.
Date Of Cremation '' ((
IV c�le�, r 3 Z
Time Cremation Started
Time Cremation Completed
lI 111,to 10
Type of Container CA
-
Remarks
A� 10' S 5
Moo-
----------------
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-. / J
(City) (State) (Zip ode)
who died on- ! day of 20 6z>
at 56 A)G �—
(Place) (Address)
and address of 7est living relative or name of person aut j5
Ph
(Name) ( r
Relationship to the deceased
Name of Funeral Home
IMPORTANT:
represent that to the hest of my knowledge,the deceased(has)or maker,defibrillator,battery,battery pack,power
cell,radioac a implant or radioactive device in his or her body.(Circle One)
I certify that I have full power and aultxx zatlon to arrange for the cremation 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 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 nected with the cre of said remains as directed,whether such daims or demands are or are notwholy n
Bless,false fraudie�i(.
' � ) Address) '
(Signature and Address of Rikitive 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 specify: W`
If puNertzation of cremated remains is requested,check here
Revision:April 18,2007