Greene, Robin �O
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PwE nEw C
EM�TERY AND CREMATORI
C��KER ROAD, Q''' ' SBURY UM
(518) 745.4EE. NEW YORK 12804
476 (518) 745'•4477
.Fame Funera 1 Director V 1Z
Date O( Crematjon Casey L
Cremation
Started
Time
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Cremation Completed
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury.New York, 12804
Cemetery Office: (518)7454476,Crematorium: (518)745-4477
Authorization to Cremate
The cnderslprred requests and autlortzes Pine View Crematorium,in accordance with and subject to Its Rules and RegUI8d0ns to
777tb
remains of
���/�
(Sex)
( ) (city) ( ) ode)
who died on d day of 20_9
at I a r
(place) O
Name and address of nearest Nvlop relative or of suoxxt*V cremadon:
1 f
(Name) ( )
Relationship to the deceased -� p
Name of Funeral Home -
IMPORTANT: the deceased(has) cul �m�y pacemaker,defibrillator,battery,betterY peidc,power
t represent that to the best of my iQnowiedge, CY�ele�arte
cell,radioactive irnplent or radloective device in his or her body.( )
I certify do I have full power and eutfwrW tfon b arrange for the cremation of the remains and to direct the disposition of the
cremated remains.so any personal por>sesdorns have eitfter been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View CremWm kxn flnom any and al chime and demands for loss or demeges vArich maybe made against them
by reason of or connected with the crernoWn of said remains as drecb I whdher such claims or demands are or are not wholly
groundless,false or fraudulent. ZSv,
to I (Address)
(Sigrnetue and Address�of Relative or legal Rive)
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pane View owneaodum to dispose of the cremated remains as follows:
Mail to
Other anvVements-Please spedfY:
if pAverintion of cremated remains is requested,do*here
Revision:April 18,2007