Behlmer, Harold OF QUEE9�50up,,y
PLNE VIEW CEMETERY AND CREMATORIUM
QU-AKER ROAD, QUEENSBURY NEW YORK 12804
(518) 745.4-476 (518) 745'•4-477
Funeral Director
Name
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Date Of Cremation
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Time Cremation Started
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Time Cremation Completed 3: 0
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Type of Container i
Remarks
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbtiry, 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
a e the remains
(Name) Zal&*tp�l
/ W&J44C AIN,
(street) (City)wa<h o d' on a�fb�l/1• V �i e
(State) (Zip Co de)
d Zu�"�r D
ey
( d Name and address of nearest living relative or name of person authoring cremation:
��rnaS ��-ch�►�v
(Name) (Address)
Relationship to the decer.3d 6Y1
Name of Funeral Home —
--"
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her body.(Circle One)
I certify that I have full power and authortMion to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,that any personal possessions have ether 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 reason of or connected with the cremation of said remains as directed,whether such claims or demands are or are not wholly
groundless,false or fraudulent.
ture Address of Relative orLegal Representative)-
Signed on this date: A
Disposition of Cremated Remains
1 hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:
If pulvertwtion of cremated remains is requested,check here
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Revision:April 18,2007