Alvarado, Irene TOWN OF QUEENSBURY
P,ne View Cemetery and Crematorium
27 Quaker Road, Queensbury, NY, 72804.5902
(518) 74 5.44 76 (518) 745.4477
htrP://wNv\v.queensbury.net
Funeral Director:
Name of Deceased: .�
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Case Number:
Date of Cremation:
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Retort:
Time Cremation Started: (2 3 U
Time Cremation Completed:
Type of Container:
Remarks:
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" Hoerr of Nnlr, ral Beauty ... A Goo ,l Place to L , ve "
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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 ai id Regulations to
cremate the remains of.. �.ti�1� .
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(Name) (Sex)rr.18 BMW/ �/}CJ
-1' ' &'e-t
(Street) (City) (State( (Zip Code)
who died on n 3o day of 2009
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(Place) (Address)
Name
land"address of nearest living relative or name of person authorizing cremation:
(Name) (Address)
Relationship to the deceased ��-�
Name of Funeral Home
IMPORTANT:I represent that to the best of my knowledge,the deceased(has)or 4ADPacemakef,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 connected with the cremation of said remains as directed,whether such claims or demands are or are not wholty
ground false or fr
#Wulent.
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(Signature�andAddress of Relat►ve or Legal Representative)
Signed on this date:
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 pulvertzation of cremated remains is requested,check here
Revision:April 18,2007