Weil, Nicholas �Q
F QUEEN5rBUT0,,PWEYIE
W ,CEMETERY AND CREMATORIUM
qu— Kk R ROAD, QUEENSB RY, NEW YORK 12844
(518) 745.4476 (518) 745'•4-477
Funeral Director
Name SS W
e� Case#
Date Of Cremati.on
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Time Cremation Started
Time Cremation Completed
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Type of Container
Remarks
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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 aulhorkws Plre View Crematorium.in accordance with and subject to its Rules and Regulations to
cremate the remains Olt
(Name) (sex)
(Street) (City) (state) P )
day of
who died on
at (Address)
(tom)
Name of nearest Wing relative or name of person
(J a 717
—
(Name) (address)
Relationship to the deceased �'T6
Name of Funeral Home /� C^ > �/n r—t l.�J�Z
IMPORTANT:i repraserrt that to the best of my Ivwwiedge,the deceased(has)or(has no)Paoef,deAbrilletar, •battery pads,Power
call,radioactiveimplantor radioactive device in his or her body.(Ckde One)
I certify that I have full power and arxhorbWAon 10 atrertge for the aernation of the remains and to drect
the agree to aotect,Ofdetend and
wve
cremated remains,that arty personal Po ha e0w been removed or may be destroyed.
and View Uom any and afi debts and demands for loss or damages which may be made against them
save byreaso n0f Ilse cremation of said remelts as dimcled. srx h clelrns or demands are or are not wholly
grO1r'dless, or
(Signatrxe and Address R or Legal epresarntet )
on this date:
Disposition of Cremated Remains
I hereby direct Pine View Cmnatoritxn to dispose of the aemated remains as til ws:.
Mail to
Other arrangements'Please sPeW-
It pulverization of cremated remains is requested.checit here
Revision:April 18,2007