Shores, Pauline OF QUEE9�50ur�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
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Date Of Cremation
Time Cremation Started ;D S
Time Cremation Completed
TYPe of Container
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 ot.
(Name) (Sex)
(Street) (City) ( e) (Zip Code)
who died on day of 20g
at a
(Place) ( )
Name and address of nearest lliivviing relative or name of penmen aLftwb v cremation:
e
(Name) (Address)
Relationship to the deceased ma`s
Name of Funeral Home
IMPORTANT:
I represent that to the best of my Wwwledge,the deceased(has)I
(has Pacemaker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her body.(Cr )
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
groundle7 false or fraudulent.
(vvrtness) (Address)
X C&-� rfl
(Signature and Address of Relative or Legal Representative)
Signed on this Pe: c CU
X
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