Muller, Edith OF
PINE QUEE9\�5�BU q�J
E V7EW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY NEW YORK 12804
(518) 745.4476 (518) 745•-4.477
_ Funeral Director
Name � a
Date of Cremation C a s e# 35%
fa3 260 y
Time Cremation started
Tame Cremation Completed
Type of Container
151-
Remarks S�
11,00
,
M�
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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 audw zes Pine View Crematorium,In accordance with and subject to its Rules and Regulations to
cremate the remains of:
!"'
(Name) (Sex)
(Street) (City) (Ste") (Zip ode))
who died on day of" 20
(Place) (Address)
Name and address of nearest living relative or frame of person authorizing=T(Wion:
(Name) ( )
Relationship to the deceased
Name of Funeral Home ':'
IMPORTANT:
I represent that to the hest of my browledge,the deceased(has)or(has no)pacemaker:defibrillator,battery,batten'pack,power
cell,radioactive implant or radioactive device In his or her body.(Circle One)
I that I have ftA power and authorhation to arrange for the Cremation of the remains and to direct the disposition of the
remains,that any personal posses have either been removed or may be destroyed.and agree to protect.defend and
seveharmless Pure View Crenuwlum from any and all claims and demhands for loss or damages which may be made against them
by of or connected with the cremation of said remains as directed,i bow such claim or demands are or are not wholly
gn less,false fraudrkgd
( )
nature and Address of Relative or Legal Representative)
Signed on this „ " J.le�-+'+^-�
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