Emery, Danny L OF UE�
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PTNE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QfEENSBURY NEW YORK 12804
(518) 745-4476 (518) 745-4-477
Funeral Director
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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 Regutat* to
cremate the remains of: /
(Namek U (sex)
(Street) `A (City) (State) (zip Code)
who died on � day of J. 20 O(5
at M
(Place) ' (Address)
Name and address Of nearest living relative or name of person aut?'9rulng cremation: �)
''` of
( ) ass)
Relationship to the deceased '
Name of Funeral Home a r-.r
IMPORTANT:
I represent that to the best of my Iv�e,the deceased(has)or(has no)pacemaker,defibrillator or any other battery operated
device In his or her body. (Circle One)
I certify that I have full power and auawtZ800n to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,that any personal possesslons have either been removed or may be destroyed,and agree to protect,defend and
save harmless fine View Crematorium from any and all claims and demands for loss or damages which may be made against mem
by reason of-of corvtected with the creration of said remains as directed,whether such claims a demands are or are not whoity
and or fraudulent. [ u
Mrn ) &�i 2 Address) i.� r. U d 2
lgn re and Address of Relitive or Leg Representative)
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mall to
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
Revision:January 1,2006