O'Keefe, Donna 0 1
CEMZTERY AND
�O'�R ROAD, CREMATORIUM
QVBENSBURY, NEW YORK 12804
(518) 745.4476 (518) 745'.4.477
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Funeral Director
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Town of Queensbury
Pine View Cemetery and Crernatotiuni
21 Quaker Road, Queensburyy, New York, 12804
Cemetery Office: (518) 745A476, Ciernatmiurn: (518) 745-4477
Authorization to Cieniate
The undersigned requests and authorizes Pine View Ciernatodurn,In ack.vrdarxo with and sub)ec-t to its Rules and Regulations to
emate the remains of: V
(Name) (Sex)
(Street) (City) (state) (zip c(xJe)
who died on day of �-ri -. —-.-----20
at
(Place) ( less)
Name and address of nearest living relative or name of person auttxxizirig cremalkxi:
(Name) (Address)
Relationship to the deceased ------ -------
C-
Name of Funeral Home
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(ties no)pacemaker,defitxillalor,battery,battery pack,power
cell,radioactive Implant or radioactive device in his or her body.(Circle One)
I certify 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 persona(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
groundless,false or fraudulent.
0A,
( �) (Address) - —
(Si I ature and Address Relative or legal Representative)
Signed on this date:
` ---- - --
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:
If pulverization of cremated remains Is requested,check here
Revision:April 18,2007