Young, Charles F QU E E 9Q t3 U
PINE VIE'4y CEM TERM AND
CREMATORIUM
t E�')\KpR ROAD, Q�ENSBURY, NEW YORK 12804
(518) 745.4476 (518) 745-4477
Name
Funeral Director Ai���
C�4wLs l,' — f
u un-
Case#, CC1�
1
Da�te Of Cremati.on -�Tame Cremation Started
Tame Cremation Completed
ID
Type of Container f
G
Remarks lSl l'�45�
o
- �i v
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� G63
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 requeets and authorizes Pine View C rs"W orium,in accordance with and SUbjea to its Rules and Regulations to
cxerttate the remains ot
(Name) (Sex)
(Street) (may) (Stits) (Zip Cam)
who died on of '�
O O
Name and address of nearest Wft relative or name of person a twrfdng aemation:
(Nam) (G ( )
Relationship to the deceased
Name of Funeral Home --
IMPORTANT:
I represent that to the best of my lvowledge,the deceased(ties)01Rhas no alter,deftirillator.battery,battery pack,power
call,raftecdve implant or radioactive device in his or her body-
I certify that I have U power and aulhori=dW to aoange for the aWWd0n of the remains and to direct the disposition of the
caarnated remeM that any personal possessions have e8iter been removed or may be destroyed,and agree to pnOlem defend and
save harmis a pire View Crernetoitxn from any and an ciairrrs aid demands for k as or damages which may be made against them
by reemn of or aomacsed wide the awnadon of said nark as dreGed.WINO r such cf E l i or demands are or are not wholy
groundless,false or fiaxitilent.
( Address cf or Legal Representative)
Signed on this date:
Disposition of ownsted Remains
I hereby direct Plena View Cremataritxrr to dispose of the cremated remains as t1lows:
Mail to
Other arangernems-Plesse spew.
if pulverization of aemated remains is requested,d*&here
Revision:April 18,2007