Taylor, Grace OF
PL1YE QUEE9\�5BUTCEMATE Rt��lFCER `Y ANDCREMAT YIEpy `J
ROAD, QUEENS8VRY NEW ORIUM
(S18
(518) 745.4-476 YO 17804
) 745•4q 7�
_ Funeral -Director
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Oate Of Cremaion Casein
J
T 'me Cremation Started _
rted
Time Cremation IZ zGa9
_ ~S h
Completed l
Type of Container
Remar 'KS 6�e�^ c. hu
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--------------------------
30
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
c rematp the remains of:
(Name) (Sex)
(Street) (City) tale) (Zip Code)
who died on day of 206*4!7
at
(Place) (Address) - ---
Name and addreof nearest living relative or name of person authorizing aernatkxr
(Name)
� /1zli.�L - . i S✓ r(Addr )
Relationship to the d
Name of Funeral home �'
IMPORTANT:
I represent that to the hest of my knowledge,the deceased(has)0
lies no pacemaker,defibrillator,battery,battery pack,power
cell,radkxa a implant or radioactive device In his or her body.(Cir a 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 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
ground ,false or fraud t.
(w )J ( ess)
n ,
al
(Signature and Address of Re'1619a 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