LeBarron, Harry OF QUEE9�593Ur
PINE VIEW CEMETERY AND CREMATORIUM �y
QUAKER ROAD, QUEE.NSBURY fix, YORK 128N
(518) 745-4-476 (518) 745.-4-477
Funeral Director
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Dace Of Cremation
Time Cremation Started
Tame Cremation Completed 10 Z?
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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 of:
Narm
( eet) (City) (State) (Zip )
who died on ` 5( G day of 20—
at ✓ P A�F
(Ph") 1; � (Address)
Name add nearest living relative or name of person authortzing cremation: -
(Name) (Address)
Relationship to the deceased �1
Name of Funeral Home
IMPORTANT: deceased( )or(�no)pacemaker,defibrillator,battery,battery pacts,power
I represent that to the best of my knowledge,the
cell,radioactive implant or radioactive device in his or her body.(Circle One)
I oar*that I have U power and authorization to rr rgeei r « remains�� �the t disposition�of
and
cremated remains,that any persona possessions whichY made them
save harmless Pine view Crematorium from any and all claims and demands for bss or damages
bi3LL
reason of or connected with cremation of said remains as directed,whether such claims or demands are or are not wholly
(Address)
Legal Representative)
Signed on this date: j C/ a a
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 pulverization of cremated remains is requested,check here
Revision:April 18,2007