O'Malley, Alice t
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E'WCEMETERY AN
QU�3CPR T ROAD CREMAORIUM
(518) 74�44 6 SBURy1 NEW YORK 12804
(518) 745.4477
Funeral Director
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Date Of C r e m a t i.o n -•----4[-
Time Cremation
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T :me Cremation Completed 31100
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12844
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 Requtatbns to
cremate the remains of
(Name) (Sex)
..tG r3
(Street) (City) (State)
RIP Code)
who died on _ f� day of 20A-
at WeA
(PLace) ress)
me and address of nearest living relative or name`of person authoriz)ng cremation: �y
(Name) ( ess)
Relationship to the deceased
Name of Funeral Home
IMPORTANT:
I represent that to the best of my iQhowledge,the deceased(hasl-6r(has no)pacernakk defibriltator or any other battery operated
device in his or her body. (Clyde One)
I CeNfy 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 poesesslom have either been removed or may be destroyed,and agree to protect,detefV ano
save harmless Pine View Crematorium from any and all Claims and dernends for loss or damages which may be made against them
by reason of-of connected with1he cremation of said remains as directed,whether such claims or demands are or are not wady
groundless,to t.
},.t,�� 4 � vc �r.�— N f �►C0�
(Address)
�rX
(Signature and Address of Relative efr Legal Representative)
Signed on this date: 1 / ( /cam
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated rernalns as follows:
Mail to
Other arrangements-Please specify:
If PuFvertzation Of cremated remains is requested,Check here
Revision:January 1,2006