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Jensen, Clifford �O OF �`vR CEMIT RY AND ROAD, q, . -e CREMATp V (S 18) 741.4.471 R I UM (S181�W PORK 128pq 745.44 7 ,Fame C(� G(� FUnera l Director Date p f Cremation Case S Time Cremation Started Time Cremation 1 'V� Completed 3(� Yj Type of .Container // Remarks tf . -gip* Town of Queensbury Pine View Cemetery and Crematorium 21 Quaker Road, Queensbury, New York, 12804 Cemetery Office: (518) 745-4476, Crematorium: (518) 745-4477 t Authorization to Cremate aundersgned requests and authorizes Pine View Crematorium,In accordance rlAwlakp Cc— with and subject to its Rules and Regulations to (Na ) (Street) 66� (City) who died on r"( (Stale) (ZIP Code) day of 00. � at 20 Name ds Of nearest im l 7 a rtg rea ear t a ( ( ) �z2Z Relationship to the diaceal Name of Funeral Horne IMPORTANT: i represent that to the best of my lctowladga the deceased has or device in his or her body. (Circle pyre) ( ) rto or any other batte ry operated I certify that 1 have full Power and authorization to arrange for the ©� cremated remains,that cremation of the remains and to direct the disposition of the save harmless Pine View m�have either been removed or maybe destroyed,and agree to protect,defend and by reason of or the cremation off said remnd all ains es directed,demands for loss or damages which may be made �ulertt. whether such claims or demands are or are w l We 7 � ,h- (Signatu Address of tive or Legal RePresentative) Signed on this date: a / y' O Disposition of Cremated Remains I hereby drect Pine View Crematorium to dispose of the cremated remains as follows: Mai to Other arrangements-Please spel If pulverization of cremated remains is requested,dxxk here Revision:January 1.2006