Lufkin, Carl OF QUEE9�Sou�Ky
PINE VIEW ,CEMETERY AND CREMATORIUM
QUAKER ROA, D, QUEENSBURY, NEW YORK 17804
(518) 745.4476 (518) 745'.4.477
Funeral Director_ ( L
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Time Cremation Started
Time Cremation Completed
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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 and authorizes Pine View Crematorium,in nce with and subject to its Rules and Regulations to
crne ,te Mtheir, : -ri,
(Name) � (Sex)
(Street) (City) (State) (Zip C/o�de
who died on. day of /�Vli 20 Yf
at (Adder)
Name and of mg relative or name of person cremation:
WIze0l
(Name) (Address)
Relationship to the deceased
Name of Funeral Home vlr�
IMPORTANT:
I represent that to the best of my WmIedge,the deceased(has) has no) er,defibrillator or any other battery operated
device in his or her body. (Circle One)
Ire at that I have full power and authorization to have either been removed for the cremation or ma the ny be ns and to direct the destroyed,and agree two protect,defend and
On Of the
cremated remains,that any personal possessions l claim and demands for_or damages which_be made agebrist
by reason of or wed w e cremation of said saw harmless Pine View Crematorium from any and alremains as direct whether such claimsdemands are or are�Ny
groundless,false or fraudulent.
(Witness) ( )
(Signature and Address f Relative or Legal Representative)
Signed on this date: %//✓]p
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:January 1,2006