Ridings, Shirley OF
QUEE9�" O TO�-
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 17804
(518) 745-4-476 (518) 745-4477
Funeral Director I AKE�
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Date Of Cremation
Time Cremation Started I ; UU
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Tame Cremation Completed
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Type of Container II
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Town of Queensbury
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 undue requests and authorizes Pine view Cce ,In accordance with and subject to its Rules and Regulations to
cremate the remains of
(Name) (Sex)
-
(Street) (city) ( ) (Zip Code)
who died on day of. 20 air
at (Place) )
Name and address of nearest living relative or name of person uthoridn8 cremation:
"DI Aw,uc �2son�. /d�sWIdic l
(fie) (Address)
Relationship to the deceased
Name of Funeral Home
IMPORTANT: the decemed f m)or Qm no)pacemaker.�.fey.fly pack,per
I represent that is the best of my browledge,
cell,radioactive implant or radioactive device in his or her body.(Cr+de One)
I certify that 1 have U power and atdwdzMm to arrange for the cremation Of 90 remains and to direct the disposition of the
cremated remains.that any pepjMW p haveelaw been removed or maybe destroyed and agree to protect,defend and
save harmless Pine Visor OrerrratorNim team any and as rld and dema nds for bss er dewre8es widdr may be made against them
by reason of or connected wit the O emadon of said remains as directed.%*811I er srrdr cldims a demobs are ar are not whdly
,false or
(Witness)P (Address)
(Signature and Address of Relative or legal Representative)
Signed on this date:� ,'_ �j • �O
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as MOWS--
mail to
Other arrangements-Please specify=
if pulverization of cremated remains is requested,c hedt here
Revision:April 18,2007