Bull, Robert PINE QUEE9\�5(13U (��
E VIEW CEMETERY AND CREMATORIUM
QUA —E—R ROAD, QUEFNSBURY, N-EW YORK 12844
(518) 745-4476 (518) 745-4477
D j Funeral Director
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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:
(Name) O�/Wt ,I y , I) qw i
(Street) (City)3� C�' ` ' � '� (suite) (Zip Code)
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who died on / 3 (fey of—�`-" 20 JE-9
at
(Place)
(Address)
Name and address of nearest living relative or Warne of person withor zsV c re oration:
6�1 ice ,-r 3 a Co
(Name (Address)
Relationship to the deceased S f S rC
Name of Funeral Home
IMPORTANT:
I represent that to the NO of my ioiowledge,the deceased(has)cr ra maker,deflibriNakx,battery.battery pack,power
mil,radioactive implant or radioactive device In his or her body.(C )
I certify that I have t A power and a tiortzetbn 1D arrange for the cremation of the remains and to direct the disposition of the
cremated remains,that any personal possessions have e0w been rnoved or may be destroyed,and agree to protect,defend and
save harmless Pine View Crematorium from any and aft anima and demands for loss or damages which may be made against them
by reason of or connected with the cremation of said remains as dmcied,whMher such claims or demands are or are not wholy
groratdles%false or fraudulent- y�f
YOYA
ignature and Address JZ' or L �--A��Ive)
Signed on this date: s,A- 1 r`O�
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mali to
Other arrangements-Please specify:
If pulverization of cremated remains is requested,dtedc here
Revision:April 18,2007