Binley, Lois TOWN OF Q UEENS B UR Y
Pine View Cemetery nerd Crematorium
21 Qunker Road, Queensbury, NY, 72804.5902
(518) 74 5.44 76 (518) 745.4477
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Funeral Director:
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Name of Deceased:
Case Number:
Date of Cremation:
Retort:
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Time Cremation Started: iZ 3,U N
Time Cremation Completed: Z 3 v h
Type 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.yy�� }}
Lo>S Dl�lc�i, Fe�rra_��
(Name) (Sex)
_ )2 e'YYYhL. b�UC LaJV Ci✓i a�V
(Street) (City) ( e) (Zip Cam)
who died on C5 day of � ZOQ$
at
( ) (Address)
Name and address of nearest living relative or name of person authortang cremation:
(Name)
Reiatlonship to the deceased
Name of Funeral Home
IMPORTANT:
I represent that to the best 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 1 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'agatnst them
by reason of or connected with the of said remains as directed,whether such claims or demands are or are not wholly
groundless,false or fralidaim.u
(Address)
(Signature and Address of B61ative 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 pulverization of cremated remains is requested,check here
Revision:April 18,2007