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P LN E YY E
CEMI TERM AND
'C�l�•hK�t ROAD, CREMATORIUM
QUEENSBURY, NEW YORK 12804
(518) 745.4A76 (518) 745"4.477
E'uneral Director
fin._
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;a ; e Of Crematl. se
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' • Te , 7emati0n
Started
Time Cremation Completed
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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
cremate the remains of: _
(Street) _(City) (State) (Zip Code)
who died on r� r day of c-h 20 C
at �l� S ' 1� H G2 C-c yU.
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
Ave
(Name) (Address)
Relationship to the deceased jeak e--)
Name of Funeral Home C s rc 1 H. J.
IMPORTANT:
I represent that to the best of my knowledge,the dace (has) (has nobrillator or any other battery operated
device In his or her body. (Cl cle 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 etcher been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View Crematorium from any and all cialms and demands for loss or damages which may be made against
by reason of-of connected with the cremation of said remains as directed,whether such claims or demands we or are wt"ty
r fraudulent.
(Witness (Address)
X C O
(Signature and Address of Relative or Legal Representative)
Signed on this date: l Y
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 pulvertration of cremated remains Is requested,check here
Revision:January 1,2006