Bombard, Mary OF
P LNE QUEE9\�50ur,�
VIEW CEMETERY AND CREMATORIUM
QUAkER ROAD, Q�gNSgURY, NEW YORK 128o4
(518) 745-4476 (518) 745'-4.477
Funeral Director
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.. Case# _�34
Dare Of Cremati.on
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Time Cremation Started
Time Cremation Completed
Type of Container 7r4S—
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Remarks
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Town of Queensbury
Pine View Cemetery and Crernatodu►n
21 Quaker Road, Queensbury, New York, 12804
Cemetery Office: (518) 745-4476, Ciernato6urn: (518) 745-4477
Authorization to Ciernate
The undersigned requests and authorizes Pine View Crematorium,In accordance with and subiect to Its Rules anv I Regulations to
cremate the remains I
(Street) (City) 1 ( ate) (Zit)/Code)
who died on �" day of
at 1� --
(Piece) -
Name'and address of nearest living relative or name of person authorizing ctematikxh:
(Name) (Addy\ess)
Relationship to the deceased
Name of Funeral Home
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)6
(has no maker,defiWllator,battery,battery pack,power
cell,radioactive Implant or radioactive device In his or her body.(Cir e
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 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 kx are not wholly
groundless,false or fraudulent.
(Witness) (Address)--- — --
�. /7 a= --
(Signs ure and Addr of Relative or Legal Representative)
Signed on this date: \ `
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