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WE VIEW CEMETERY AND
CREMATORIUM
QUAKER ROAD,
QLIEENSBURY, NEW YORK 12844
(518) 745-4476 (518) 745'-4477
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Time Cremation Started
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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 aril autlhorizes Pkhe Vow Crematorprm, a000rdanc�e with and subject to its Rules and Regkr�tiorhs to
cremate the remains of:
(Name) (sex)
S-- C� iLJ L /2 e-V �f
Stale (ZP Code)
(Street) t (�Y) (
who died on /3 of U L ^ 20_—
(per) revs)
Name and address of nearest truing relative or name of persontul hortzIng cmmation:
(Name) ( )
Relationship to the deceased
Name of Funeral Home
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker. .may,battery Pam,Power
cell,radioactive implant or radioactive device in his or her body.(Circle One)
I certify that I have RA power and ardfwrization to anartpe for the aemation of the r+errreins and to direct the disposition of the
cremated remains,that any personal possessions have ether 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 w hedw such claims or demands are or are not wholly
groundless,false or fraudulent.
(w ) C )
(Signature 7()
elative or Lagal Representative)
Signed on this date: � /y d�
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows'
(Nail to
Other arrangements-Please specify:
if pulverization of cremated remains is requested,check here
Revision:April 18,2007