Botsford, George J .
(7-O OF QUEE9�SBU2r
PINE VIEW CEMETi✓RY AND CREMATORIUM
gUAXER ROAD, Q�lggjlSgUR�, NEW YORK 12804
(518) 745.4476 (518) 745-4477
Funeral Director r�s
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Date Of Cremation
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Time Cremation Started
Time Cremation Completed
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Type of Container /
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Remarks SI C
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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 undersigned requests eod authortms Pine View Crematorium,in accordance with aW sub)ect to Its Rules and Regulatlom to
cremate the remains of: �1 Q
677eo rq
(rVame) tom)
�039 31 Pm 14-vod. Qs�
(Street) / (City) (State) (Zip Code)
who died on __/ 729
^c;?17O� day of 20=
at
(Plow) (Address)
Name and address of nearest living reiative or name of person etdhorizing cremation-.
(Name) � X 3 SFG� VT��',
�. c ) I t PVT—0S76�
Relationship to the deceaseed��.
Name of Funeral Home
IMPORTANT:
I represent that to the Mast of my knowledge,the deceased(has)or, no maker,defibrillator,b0tery,beftery pack,power
al
cell.radbsciive Implant or radioave device In his or her body.(C
I certify that I have full power and authorization to arrange for the osmetion of the reMalfts and to direct the disposition of the
cremated remains,that any personal possessions ha"either been removed or may be destroyed,and agree to prolect,defend and
save hafmless Pine V1ew Crematorium from any and all Balms and demands for toss or damages which may be made against them
by reason of or connected with the cremation of said remains as directed,whadw-such daims or demands are or are not wholly
groundless.false or
Jewl Ilele,*" 1011
(Signat and Address 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:
It pulverization of cremated remains is requested,check here
Revision:April 18,2007