Bailey, Louis OF QUEEN,5BU-r)�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745•-4.477
Funeral Director_ _
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Date Of Cremation � (2`
Time Cremation Started
Time Cremation Completed 0 ; 1 '0
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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 accordance with and subject to its Rules and Regulations to
cremate the remains
(Name) (Sex)
(Street) (City) (State) (Zip Code)
who died on day of
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
(Name) r� (Address)
Relationship to the deceased ��l
Name of Funeral Home 116 Lb?�/N I
IMPORTANT:
I represent that to the best of my Ivtowledge,the deceased(has) �no"aker,defibrillator,battery,battery pack,Power
cell,radioactive implant or radioactive device in his or her body.(Cir )
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 claims and demands for loss or damages which may be made against them
by reason of or connected with the cremation C4 said remains as directed,whether such claims or dernands are or are not wholly
,false or fraudulent.
e (Wdness (Address)
(Signature and Address ol Relative or Legal Representative)
Signed on this date: I 1 o k 7K
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to t�
Other arrangements-Ply specify: 'ems
If pulverization of cremated remains is requested,check here
Revision:April 18,2007