Stewart, David TO TOY7� OF QUEE�S
B U(�yRLNE VIEW CEMETERY AND CREMATORIUM
'Q'VXkF-R ROAD, QUEgNSB RY, NEW YORK 12844
(518) 745.4476 (518) 745.4477
Funeral Director_ '
Name Adic� �tcwc+�i'
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Date Of Cremation I
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Time Cremation Started ?:3U
Time Cremation Completed
Type of Container
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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 authorizes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
(Name) (Sex)
(Street) Vt' (City) (State) (zip Code)
who died on day of IJ c v 20 b 6
at w
(Piece) U j (Address)
Name and address of nearfest living relative or name of�Jauthorizlngq��{cremation:
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( me) (Address)'
Relationship to the deceased
Name of Funeral Home n. .-
IMPORTANT-
I represent that to the best of my knowledge,the deceased(has)ordQ no)pacemaker,defibrillator or any other battery operated
device in his or her body. (Circle One)
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I certify that I have full power and authorbmtion 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 claims or demands are or are not wholly
9 lord
(Wltnessy (Address)
-(SIgnatureInd Add Jess of Relative al esentative) , 9
Signed on this date: o J
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mall to
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Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
Revision:January 1,2006
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