Gregory, Helen OF
P LN E QUEEN,50UrRT r
VIEW CEMETERY AND CR
QUA�CER ROAD, EMATORTUM
QUEENSBURy, NEW YORK 128C4
(518) 745-4-476 (518) 745-4-477
Funeral Director "I) j/
.Fame C � F , /,at
�� � vr C a s e#Date Of Cremation
Tut �,U
Tame Cremation Started Zook
'; Zo
Tame Cremation Completed
��l(3
Ty ?e of Container u;i• n;nrr F
Remarks s ISj
I =3v
fw()LJE z I
ML
Town of Queensbury
Pine Yew 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 Regulations to
cremale theiremain of:
5 A 4L
�LY12Wq
(Street) COY) (State) (Zip Code)
who died on day of 20tT
at
(Place) — (Address)
NAme and add of nearest living relative or name o person
Q, qvmbqp:
(Name) �V u ram)Relationship to the
Name of Funeral Home fi 4
IMPORTANT:
I represent that to the best of my krwwledge,the deceased(has)a (��5 Pacemaker,defitxfllator,battery,battery pack,power
cell,radioactive implant or radioactive device In his or her body.(Circle One)
I certify that I have full power and authorization to arrange for the cremadm of the remains and to direct the disposition 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 wholly
groundless,false or fraudulent.
(Witness) (Address)
(Signature and Address of Relative or Legal Representative)
Signed on this date:
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 pulverization of cremated remains is requested,check here
Revision:April 18,2007