Morris, Eleanor OF QUEE9�50ur
PLNE VIER' CEMETERY AND CREMATORIUM
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QUAKER ROAD, QUEENSBURY NEW YORK 12804
(518) 745.4476 (518) 745-4477
Funeral Director J
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Date Of Cremation '
Time Cremation Started
1 - 30
Tame Cremation Completed
Type of Container c,rc
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Town of Queensbury
Pine View Cemetery and Crematotium
21 Quaker Road, Queensbury, New York, 12804
Cemetery Office: (518) 745-4476, Crematorium: (518) 745-4477
Authorization to Crernate
The undersigned requests and authorizes Pine View Crematorium,In acckxdat"with and subject to its Rules awl Regulations to
cremate the remains of:
(Name) (Sex)
(Street) (City)) ---�T (state) (Zit,Code)
who died on __ day of
at G enS 4 \S V - - . ---— --
(Place) (Address)
Name and address of nearest living relative or name of person auttxxizirhg ctematiun:
(Name) (Address)
Relationship to the deceasedS
Nam of Funeral Home
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,defitxillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her body.(Circe 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 harmless Pine View Crematorium from any and all claims and demands for loss of damages which may be made agairlst them
by reason of or connected with the cremation of said remains as directed,whether such claims or demands are or are not wholty
groundless,false or fraudulent.
CA"ess-)-
All -- -- —
(Signs a and Address of R tive or Legal Representative)
Signed on this date: \� 3 _ - - -------- ---_
Disposition of Cremated 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 _-
Revision:April 18,2007