Wilcox, Betty r:
OF QUEEPINE YI ��
Ems' CEMETERY AN9D
CR
QUAX11A ROAD, Q >?NSBURY EMATORIUM
(518) 745.4476 NEW YORK 12804
(518) 745-4-477
Funeral Director (3
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Time Cremation
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queenebury, New York, 12804
Cemetery Office: (518)745-4476,Crematorium: (518)745-4477
Authorization to Cremate
The undwsigned requests and authOrtws Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of.
(Name) (sex)
�3 0 s r l—0
(Street) (fir) (ate) (� Code)
who died
at
(Place) ( )
Name and address of nearest living relative or name of person cremation:
(� ) (Address)
Retadonship to the deceased _tip
Name of Funeral Home t 1ti nl(Z !J / ( `�
/Y
IMPORTANT: /
I represent that to the bast of my knowledge,time deceased(has)or(has no)peowndw.dellbrillator,battery,battery Peck Power
cell,radioactive uylplant or radioactive device In his or her body.(Circle One)
i cagy!fret 1 hens AA power and authorizgdm to ananpe for the aemedon of the remains and to dyed the disposition of the
cremated remains.then any P a A 0 1i po413091ot10 have eiNter been removed or maybe destroyed.and agree to POW defend and
save hem*m Pine View C rematorl m from any and a/CIF irrrs and demands for bee Or damages which may be mmade agairmst them
by reason of or connected vdb the aemalion of avid renWA 0 as drected.wlratlter such delrns Or derrmards are or are not wholly
groundkgm Was or*audLdenL
f,>t�
(witness)F I (Add' )
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(Signatwe and Address of Relative or Legal Repre�antsdve)
Signed on this date:
Disposition of Cremmeted Remains
I hereby direct Pine View Crematorium to dispoee of the cremated remains as
Mail to
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Other arrangements-Please speck:
if purlverb ation of cremated remains is requested,check here
Revision:April 18,2007