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Carota- Hoke, Jordan t _ 1 TOWN� OF Q UEENSB UR Y Cemetery and Creujolori►nu 11 Quaker Road, Queenshrrry, NY. 12804.5901 (518) 745.4476 h(rP://"%v%,.queensbury.net (518)745.4477 Funeral Director: B Name of Deceased:_ ©rti I!!;, o . Case Number: Z 5 Date of Cremation: 3c, ZC)Dg Retort: Time Cremation Started: Too Time Cremation Completed: Type of Container: , C�,tSi,�r Remarks: .. Howe Of Nnlirra 8enirly ... A Goof PIRCe in . . Town of Queensbury Pine View Cemetery and Crematorium 21 Quaker Road,Queensbury,New York, 12804 Cemetery Office:(518)745.4476,Crematorium:(518)7454477 Authorization to Cremate The undersigned requests and authorizes Pine view Crematorium.In accordance with end subject to Its Rules and Regulations to aerrrere the remains of Name) (SOO fa �a n 01 (Street) (City) (Store) (Zip code) who d on day of �� 20f Namp and address of nearest Mg Native or name of person authorizing cremation: y�� s �— (Address) Relationship to the deceased cc�� Name of Funeral Home ld� IMPORTANT: I rapresent that to the best of my ivrowledge,the deceased(has)or(has no)pacemaker,defRxilator,battery.battery Pack.power cell,radioactive implant or radioactive device In his or her body.(C2rde One) I certify that I have ful power and Udwrtration 1a M Mgt for the cremation also remains and to dined the disposition of the cremated remains,that any p A I I pia have eUher been removed or maybe destroyed.and agree to protect,defend and save harmless Pine view Oramelafum ftm any ad at deists and demands for km or danrrea' vMch may be grade against them by or vMh ft of r&v"as directed.Mlisillm such claims or rim rntls we or are not wiay or (Address) (Signature and R or legal Representative) Signed on this date: Disposition of Cremated Remains I hereby direct Pine view Crematorium to dispose of the cremated remains as Wows: Mal to Other arrangements-Please sPOCIN: If pulverization of cremated remains is requested.check here Revision:April 18,2007