Cunningham, Richard OF QUEEN
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
/' Funeral Director
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Date Of Cremation f
Time Cremation Started
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Time Cremation Complete
Type of Container r l�Utirfl Cn.
Remarks
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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 81
dance with and subject to its Rules and Regulations to
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Name, P � `Se`'
(Str t) (Cm') (State) (zip Code)
who died on day of /Uo - 20P-1
at -3 &J
(place) (Address)
Name ress of pearehliving relative or me of person a creme AA(
(Name) raw)
Relationship to the deceased -5 L f
Name of Funeral Home
IMPORTANT:
I represent that to the best of my ivrowledge,the deceased(has)or pacemaker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her body.(Cv one)
I certify that I have full power and authorization 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 cairns and demands for loss or damages which may be made agair>st them
by reason of or connected with the cremation of said remains as directed,nhtedw such claims or demands are or are not wholy
groundless,false or fraudulent.
7 , > (Address)
(Signature and 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 specify:
If putverization of cremated remains is requested,check here
Revision:April 18,2007