Schermerhorn, John �O
OF
pWE Yl'EW Q EErT��
tf F-''�t3Cg}Z RO DEM1rTER Y AND CREMAT 1' �J
' QUE "BURY' NEW ORIUM
(518) 745.4.476 YORK 1280q
(518) 745.•4477
Funeral Director 1'
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Gate Of Cremation
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T1me Cremation
Started
T1me Cremation Lion Completed
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Town of QueerWwry
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 autlwrizes Pine View Crematorium.in e000rdence with and subject to its Rules and Regulation to
cremate remains of
(►`lame) T`)
/ ? 2 j1-Jen4,L*�-xJi6 /& jZ
(Street) (City) (fie) (Zip
who died on �p `� day of 7k A�20 7
at
(Place) (Address)
Na address of nearest Wit relative or name of person salmon&v
( ) (Address)
Relatior>ship to the deceased W i
Name of Funeral Home "
IMPORTANT: v
i represent to the best of my IQnowiedge,the deceased(has) ( as h .deAbriR batt etor,battery.Lack,
that ack,power
cell,radioactive ampient or radioactive device in his or her body.( )
I certify that I have full power and authorization to mange for the cremation of the remains and to direct the disposition of the
cremated remam that any penaonal possessions have either been removed or may be destroyed.and agree to protect,defend and
save harmless Pine View Crenraoorlum from any and all cleirns and demands for lose or denrages%Abell may be rnede against them
by or with the cremation of said remains as deer i n! wtrathar suds claims or demands are or are rot wholly
�T-
(Witness) Address)
(Signature and of
7/69
Relative or Legal Repr We)
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pine View CrenWork"to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please spedfy:
If pufvarization of cremated remains is requested.check trere
Revision:April 18,=7