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PINE VIEW Ur `./
VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY NEW YORK 12804
(518) 745.4476 (518) 745-4477
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Funeral Director (
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Case
Date Of Cremation (Y r
Time Cremation Started '
Time Cremation Completed
Tyke 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 of:
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S/
(Name)/ (sex) V
(Street) (City) ) (Zip Cod
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Pwho died on dayof 20 �
(Place) (Address)
.Name and G1 M address of naar �ivtng relative or name of persona767
c anon
v.
(Name) ress)
Relationship to the deceased /
Name of Funeral dome 111 )h 4l
IMPORTANT:
I represent that to the hest of my knowledge,the deceased(has)or(has no)pacemaker,defibrillator,battery,battery pack,Power
cell,radioactive implant or radioactive device in his or her body.(Circle One)
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 ed with tion of said remains as directed,whether such claims or demands are or are not wholly
ndless,false ILL- /�2-R
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(witness) /�l r
ignature a9d of Reba ive or Legal Re esentative)
Signed on this dater
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify: G hT�/ r(�
If pulverization of cremated remains is requested,check here
Revision:April 18,2007