Masterson, Kathryn OF QUEEN,5tBUr
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEaNSgURy, NEW YORK 128C4
(518) 745-4-476 (518) 745'-4,477
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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) 7454477
Authorization to Cremate
The undersigned requests and authorizes Pine View Crematorium,In accordance with and subject to Its Rules and Regulations to
cremate the remains of:
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(Name) j,/
(Street) p (City) (State) (Zip Code)
who died on 3 r day of_L!Z &I-S IL 20 a
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at
(Place) Address)
Name and address of nearest living relative or name of person authorizing cremation:
(Nam (Address)
res)
Relationship to the deceased 1/ LA �'1/ I
Name of Funeral Home
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IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)o (has no) cemaker,defibrillator or any other battery operated
dovice In his or her body. (Circle One)
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 handless Pine Yew Crematorium from any and all claims and demands for loss or damages which may be made against them
by reason of or oonnedod with the cremation of said remains as directed,whether such claims or demands are or era not wholly
groundless,false or fraudul nt.
( tlness) , (Ad
(Signs re an Address of Relative or Legal Representative)
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Signed on this date: �
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ois sition of Cremate
po d 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
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Revision:January 1,2006
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