Russell, Ralph OF QUEEN,50ur
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12844
(518) 745-4476 (518) 745-4477
Funeral Director
Fame
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Date Of Cremation
Time Cremation Started
Tame Cremation Completed
Txpe 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 ac ordenoe with and subject to its Rules and Regulations to
cxerrrate the of:
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(Street) I (City) e) VJP Code)
who died on / 9 of—3 v
at
(per) (Address)
Name address of nearest Wving relat n nacre of person ae nedon:
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(Name) (Address)
Relationship to the deceased
Name d Funeral Home
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IMPORTANT:
opb b or radioactive ledge
device b his b(ha (Circle )pacemaker,defibrillator,battery,battery Pack,Power
I oe*that I have full power and BAW t oon to mange for the aNnUtion of the remains and to direct the disposition of the
c reme"ed remains,that any per9onel possessions have slump been renaved or may be destroyed,and agree to protect,defend and
save Pine View Crerrraivmium from any and a/chins and demwds for bss ar damages which may be made against them
by of or the cremation of said remain as drected,whe�er ouc(h3china a demands are a are not wholly
Witness)
( ignature Legal R )
Signed an this date:
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:_
Mail to
Other anarrgernents-Please specfy:
If pulvertzation of cremated remains is requested,check here
Revision:April 18,2007