Wood, Kenneth r-r
L O O ( .
pWE V1E `'L EE9�5B
W CEM'MRy AND CREMA R ROAD, q- - - 8 TORIUM
(518) 745. ME URY, NEW YORK 12804
(518) 745'.4477
Name Funeral Director
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Time Cremation
Started
Time Cremationf-Os
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Town of Queensbuiy
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office:(518)745-4476,Crematorium: (518)745-4477
Authorization to Crernate
The undersVied requests and audwriaes Phre View Creoratodum,in a000rdenoe vAlh and subject to its Rules and Regulatlons to
cremate the rema of:
(Name) ) D � /�i6
1 Z � 1 vlz �-T
(street) (city) (scatef 0 code
who died on
at (Place) ( )
Name and address of nearest living or name of a
.
(fie) (Address)
Relationship to the deceased —ef—
Name of Funeral Home / L �r
�y
IMPORTANT*
i represent.
that to iha best of my 10VA0180gO,the deceased(ties) (his rto) ,defi�tor.battery,battery pack,pwAsr
cell,radioactive implant or radioadrve device in his or her body
i certify#sat I have fug poow and aowftgW►to arrange for tlhe aW6811oo of Hie remsim mid to direct the disposition of the
cremated remem that any persongipossessioris have eidw been famoved or atay be destroyed•anti agree to protect.defend and
save harmless the a rra6On d said r�oaMs dise�ed, sucht ar denrerds we or an not wholly
by resort
groundless, r A7
srtess (Address) vC
(StroWm and Address of R or �)
Signed on this date: ' Z Z/
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as fdiow ..
Mail to
00w arrangements-Please speofty:
If pulverization of cremated remains is requested,dm&here
Revision:April 18,2007