Burch, Jeffrey T0
wy� OF QU
. PINE YTEvy CEM ���T��
E CREMATERY AND
'qE4ylKER ROAD, QVEL°NSBURY TORIUN!
(518) 745.4476 W YORK 12804
(S18) 745-4.477
Fame
Funeral Director
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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 author¢es Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the Ins of:
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Iq
(Street) Uq (City) (State) (Zip Code)
who died on day of 20Al
at
(Place)
( (Address)
Ime and nearest I T
name of person authorizing cremation:
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YU - W - M�
(Name) n(Address)
Relationship to the deceased il'A
Name of Funeral Home
IMPORTANT:
I represent that to the best of my loiowledge,the deceased(has)or(has no)pacemaker,defibrillator or any other battery operated
device In his or her body. (Circle One)
I oertity that I have full power and authorization to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,that any personal possessions have either been removed or may be destroyed,and agree to protect defend and
save harmless Pine View Crematorium from any and all claims and demands for loss or damages which may be made against them
by reason of or connected with the cremation of said remains as directed,whether such daims or demands are or are riot wholly
groundless,false fraudulent.
\ (,address)
S and Address of R ittve or Legal Repr�eseenntative�)
Signed on this date: eSOICA—) � `- v
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 Pukwbatj0n Of cremated remains is requested,check here
Revision:January 1,2006