Nedell, Marie M -
OF QUEE9�,-593U,
E VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY NEW YORK 12804
(518) 745.4-476 (518) 745-4.477
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.
IM"2UE N
(Name) �� �LAAJ
(Sex)
3i� 211J i' - - f z82.8
(Street) (City) (State) (Zip code)
who died on 11A z day of NJW Ale _20 6S
at 44. h) t 'i L
(Piece) (Address)
Nam and address of nearest living relativ or name of person authorizing cremation:
CJ w la Zt: W4 ub �o Box 4511 , 19 wgM(4g-y ley
(Name) (Address) —T--T
Relationship to the deceased ,o1Dt,l�
Name of Funeral Home.,
IMPORTANT: ��
I represent that to the best of my knowledge,the deceased(has)or_(nas now D"maker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device In his or her body.(Cir )
1 certify that I have full power and authorization to arrange for the cremation of the remains and to direct the disposition of the
ated remains,that any personal possessions have either been removed or may be destroyed,and agree to protect,defend and
sav rmless P Crematorium from any and all claims and demands for loss or damages which may be made against them
by r ed with the cremation of said remains as directed,whether such claims or demands are or are not wholly
gr udulent.
(w ) (A )
(Signature a 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 follows:
Mail to
Other arrangergents-Please specify: �.ETU�.ti1 � �L 14 "- —
If pulverization of cremated remains is requested,check here_ ✓
Revision:April 18,2007