Kuehn, Anna TO O
PINE y7E yy Q,�-1 L L r
f4� R EM ERY q
ROAD, j T VEtR BuRY NT) CREMATpR
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(S18) 745,4476 , KEW YOR}C 12804
(S 18) 745.4477
.Fame An+ic Funeral Director
D a t e
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Lion Started
Time Cremation Completed
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 128G4
Cemetery Office: (518) 745-4476, Crematorium: (518) 745-4477
Authorization to Cremate
The undersigned requests and authorizes Pine View Crernatorium,
cx t the remains of: In acccxclance with and subject to Its Rules and Regulations to
o
(Name)
kclk " I Ge��,?
(street) (City) (St te)
(Zip code)
who died on day of �•11V���.( -
(Place) (Address) - ---
Name and•` address of nearest living relative or name of person authaizhv cremation:
k? G titer. <Z1
(Name) - (/Odress) - -
Relationship to the deceased
Name of Funeral Home ---
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has) (has no) make+,defibrillator,bath
cell,radioactive implant or radioactive device In his or her body.( e One) erY.battery pads,power
Iremate at uth
that 1 have full power and authorization to a
cr rrange 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 a
by reason of or connected with the cremation of said remains as directed,whether such dais claims s asdemands are which May be n adertaogt airs t�m
groundless,false or fraudulent. are
(Witness) (Address)
nature and Address of a five egal Representative)
Signed on this date: l 1 3 1�
Disposition of Cremated Remains
I hereby tied Pine View Crenw rkim to dispose of the cremated remains as follows:
Mai to
Ortrer arrangements-Please specify:
K M*jefv9 W of nett cad retnakls iS requested,Check here —
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