Woodruff, Doris OF 1.1 L
Q 9\�sB u '�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY NEW YORK 12804
(518) 745.4476 (518) 745'-4477
Funeral Director
Name
•• Case# 39 S'
Dace Of Cremati.on
Est LS Zav�
Time Cremation Started
3v M
Tame Cremation Completed kU
Type Of Container
Remarks
N 7 c1
Town ot.aueensbury
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
cremate the remains cf.. /�r
—3>0Y' 1s W p o I ruff �erna�e
(Name) (Sex) 11
1 C UY» CU LO V1Jil y1LJ e e»SUy'N ` v J
(Street) (CRY) (fie) (Zip )
who died on Z day of 173JV1_ 20 d 8
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
u.s OL V7 CL
(Nam (Address)
Relationship to the deceased S
Name of Funeral Home a
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has) ro) maker.defibrillator,battery.battery pads,power
cell,radfoactive implant or radioactive device in his or her body.(Cir
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 reaso,.n of ed with the cremation of said remains directed,whether such claims or demands are or are not wholly
fa 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 6'{ in 4--4 Y r-Aa
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
Revision:April 18,2007
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