Byron, James OF QUEE9\�50ur
PINE VIEW CEMETERY AND CREMATORIUM
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WAXER ROAD, QUEENSBURY NEW PORK 12804
(518) 745-4476 (518) 745•-4477
_ Funeral Director_�R�w��
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Case# Iiq
Date Of Cremation
Time Cremation Started
Time Cremation Completed
Type of Container
Remarks CA
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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 mdersigned requests and authormess Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
(Name) ( )
T C
(street> (City) ( (Zip Code)
who died on day of M C h 20 0
at fdiell r—IC
(place) ( )
Name and address of nearest living relative or name of person authommig cremation:
(Name) (Address)
Relationship to the deceased 10 n
Name of Funeral Home 3 (�+A g (n C
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or1(has no pacemaker,defibrigator or any other battery operated
device in his or her body. (Circle One)
* 1 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 dam or demands are or are not wholly
.—vaLfidless,fuse or fiaudulent.
_, T ) (' )
( Address of Relative or Legal Representative)
✓ ) f I
Signed on this date.
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Malt to
Other arrargerrwi s-Please speaN:�A-t lx a a/ -- l U1,
If pulverization of cremated remains is requested,check here
I
Revision:January 1,2DO6