Wagner, Carl i
TrOvi1 OF Q UEENSB UR Y
c Ctrnrlery and Crenrahriura
(5 18) 745.4476 Quaker Road, Qrltrnsbury, NY. 11804.5902
htrp:iiw%v%v,queensbury.net (518)745.4477
Funeral Director:
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Name of Deceased:
Case Number:
Date of Cremation: ,j
Retort: rsi J Q�W t�f4 NY C c
Time Cremation Started: J
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Time Cremation Completed: I Z
Type of Container:Remarks:
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" Hoerr of Nnlurnl 8rnuly ... A Good Plncr r � ,r
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12804
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Cemetery Office: (518) 745-4476, Crematorium: (518) 745-4477
Authorization to Cremate
���de�f Qom,requests and authorizes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
(Jame) (sex)
_
' (serest)
(CnY) (State) (Zip Code)
who died on `� / day of , e 2009
at ✓A r 1
(Place) 0
1
(Address
Name and address of merest living relative a not of person authorizing cremation:
(Name) )
Relationship to the deceased -b,7
Name of Funeral Home -T7 rrl .
IMPORTANT:
I represent that to the best of my ivtowtedge,the deceased(has)O<Q no)paoemakalefibrillator of any other battery operated
device in his or her body. (Circle One)
I certify that I have full power and audwization to anwVe for the cremation of the remains and to direct the disposition of the
cremated remains,that any personal possessions have ettther 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 wt k h 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 wholly
�roundlesg,faW or fraudulent
(Address)
nature and A,
Address of Relative or Legal Representative)( '
Signed on this date: `ti - Q J
Disposition of Cremated Remains
I hereby direct Pine View C awdum to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
Revision:January 1,2006