Barnes, Carolyn OF
PINE QUEE9\�51BUI�y
WE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSSURY NEW YORK 12804
(518) 745.4476 (518) 745.4-477
Funeral Director
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Dace Of Cremation
Time ;?00 (�
Cremation Started
Time Cremation Completed
Type Of Container
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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 accordance with and subject to its Rules and Regulations to
a to the remains of: )�t"SL—(' 4e--(�V
(Name) 0 (Sex)
9 2 6"Irk QQ
(Street) (City) (State)
who died on g day of ���
at -�
(place) (Address)
Name and address of nearestliving relative or name of person auftrizft cremation:
(Flame) (Address)
Relationship to the deceased
Name of Funeral Homeu-
IMPORTANT:
I represent that to the hest of my Wx wledge,the deceased(has) hasno er,defibrillator,battery,battery pack,power
cell,radioactive Implant or radioactive device In his or her body.(C
I certify that I have full power and authorization to arrange for the cremation 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 tion of said remains as directed,whether such claims or demands are or are not wholly
ground fe or
(Address)
(Signature and Address of Relativeor Lebal Representative)
Signed on this date:
Dlspostion 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