Irwin, Charlotte 3 '
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TOWN OF QU'EENSBURY
Pine View Ce"Ielery and Creatalorium
11 Quaker Road, Qutenshttry, NY, 11804.5902
(518) 745.4476
http:iiwww.queensbu (518) 74S•4477
ry.net
Funeral Director: M I/
Name of Deceased: —
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Case Number: Z
Date of Cremation:
Retort:
Time Cremation Started:
Time Cremation Completed:
Type of Container:
Remarks:
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" Nontr of Natural BenulY ... A Cnnd Plnre to Live "
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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 autlarizes Pine View Crematorium,In accordance with and subject to its Rules and Regulations to
cremate the remains of
(Name) (Sex)
(Street) S (City) (State) (Zip Code)
who died on ( day of_ 20 U
at
(Piece) (Address)
Namey and address of nearest living relative or name of person authorizing cremation:
(Name) (Address)
Relationship to the deceased ';� C'
Name of Funeral Home M R Ki 1 mer Funeral Home
IMPORTANT:
I represent that to the best of my kiowledge,the deceased(has) (has no) maker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her body.
I certify that I have full power and authorization to arrange for the cremation of the remains and to direct the disposltlon 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
groundless,false or fraudulent.
Witness) (Address)
(Signature and Address of Relative or LWI Representative)
Signed on this date: J
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 putverization of cremated remains is requested,check here
Revision:April 18,2007