Chenier, Mary 0 FQUEEN
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pWE VIEW CEMETERY AND CREMATORIUM
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QUAJCER ROAD, QUEENSBURY NEW YORK 12804
(518) 745-4476 (518) 745*-4-477
Funeral Director
Name �ify �INIPr
Date Of Cremati.on
Time Cremation Started
Tame Cremation Completed 10 ; 15
T Y P e of Container a� p�,.(,Q
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 of:
{Street) (City) (State) (Zip Code)
who died on t day of t— 200
(fie) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
j
(Name) (Addr
Relationship to the deceased
Name of Funeral Home
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or no maker,defibrillator,battery,battery pack,power
cell, radioactive implant or radioactive device in his or her body.(Cis
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 cremation of said remains as directed,whether such claims or demands are or are not wholly
groundless,false or fraudulent.
�) (Address)
(Signature and Address of Relative or Legal Representative)
Signed on this date: R —
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
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) (Sex)
(Street) (City) (State) (Zip Code)
who died on CL day of 20 V
(Piece) (Address)
Name and address of nearest trying_relative or name of person 8Uth0nZUV cremabon:
(Name) 1 (AddresP
Relationship to the deceased o� f
Name of Funeral Home 3 I
IMPORTANT:
represent that to the best of my knowledge,the deceased(has)or maker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her body.(Cir
I certify that I have full power and eudxxtzation to arrange for the cremation of the remains and to direct the disposltlon 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 ions or damages which may be made against them
by reason of or connected with the cremation of said remains as directed,whether such claims or demands are or are not wholty
groundless,false or fraudulent.(Witness) ( )
(Signature and-Address of Relative or Legal Representative)
Signed on this date: R —0
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 18,2067