Peterson, Richard i
TOWN OF QUEENSBURY
Pier View Cemetery and Crematorium
17 Quaker Road, Queenshury, NY, 72804.5902
(518) 74 5.44 76 (518) 745.4477
h(rP://w%v%v.queensbury.net
Funeral Director:
Name of Deceased: ff
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Case Number: 2
Date of Cremation:
Retort: {�o—, 4
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Time Cremation Started:
Time Cremation Completed:
Type of Container: 4c.r�
Remarks:
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" Howe of Natural Benuty ... A Goo (t Plnc'e to Live "
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
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(Name) (�)
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(Street) }}�� (City) (State) (zip Code)
on V day of 20D5
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(Place) (Address)
Name and address of nearest living relative or name of person auftrizing cremation:
(Name) (Address)
Relationship to the &f✓
Name Of Funeral Home
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has) pacemaker,defibrillator,battery.battery pads,power
cell,radioactive implant or radioactive device in his or her body.(Cir )
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 con the cremation of said remains as directed,whether such claims or demands are or are not wholly
grou ,false or t.
(Address) .•+ �1.^,,,O 1
,
(Signature and Address of Relative or I-Agal Representative)-
Signed on this date: .J 1
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