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Hazzard, Louise �Q O F QUEE9�f.50Ur PINE VIEW CEMETERY AND CREMATORIUM QUA-K.ER ROAD, Q�IEENSBURY NEW YORK 12804 (518) 745-4476 (518) 745.4477 Funeral Director Fame LpV�S� �1,mer R412hrG� Case# Dace Of Cremation Tame Cremation Started Tame Cremation Completed 3' 7% � Type of Container owa� �k Z�u D remarks CA5F- M if; 3v Z:LS T 3 ' JU ------------- 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 of: ((Name) (Sex) -T (Street) (City) (State) (Zip Code) who died on _ 1� O day of Fc V - c f —,�` 20� at .� t 1 �© � 1 C C-\'�rN (Place) (Address) Name and addresss of nearest living relative �or name of person authorizing cremation: ` A � �G c.A� `JC\G r" �t�'61 �l 7' ^�K rf 11 t -if- I �H c..c) �' .k 1�'. (Name) (Address) . 1 ta� 1y Relationship to the deceased m Name of Funeral Hoe t se 1 :^nZ IMPORTANT: I represent that to the best of my knowledge,the deceased(has)or pacemaker,defibrillator,battery,battery pack,power cell,radioactive implant or radioactive device in his or her body.(Circle 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 claims 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. (Witn _ � (Address) (Signature and Address 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 fdk)ws: Mail to Other arrangements-Please specify: If pulvertzation of cremated remains is requested,check here Revision:April 18,2007