Fish, Charles LO� O
QUEE9�SoU��
PINE VIEW CEMETERY AND CR
QUAKER ROAD, EMATORIUM
QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745--4-477
Funeral Director e- �(
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Case# U6
Dace Of Cremation
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Time Cremation Started
Tame Cremation Completed
type of Container f
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
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(Name) (Sex)
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(Street) (C ) (State) (zip Code)
who fed on 2�2- day of 20�
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(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
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(Name) Q (Address)
Relationship to theom7 V
Name of Funeral He
IMPORTANT:
I represent that to the best of my knowledge,the deceased(hes maker,defitxillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her Circle One)
I certify that I have toll power and authorization to arrange for the creoff 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 Ions 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.
(Witness) (Address)
(Signature a of Relative or Legal Representative)
Signed on this date: C6
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify: rC_0 �--
If pulverization of cremated remains is requested,check here
Revision:April 18,2007