Smart, David �O O '
CEMETERY AND
��KEFt ROAD, CREMATORIUM
QUE�NS9URY, NEW YORK 12804
(518) 74S•4-076 (518) 745�•4-477
Funeral Director
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Oate Of Crematlon Case #
7 me Cremation Z
Started
Time Crematlon
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Town of Queensbury
Pine View Cemetiery 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 accordenca with and subject to its Rules and Regulations to
cremate the remains of-
v (c i'- NAn In
- - -
(Name) (Sao
(street) (City) (stste) (gyps
who died on 5 _ day of— 20 1
at
Warne and address of nearest tieing mW a or name of person authorizirg arematlon:
(Address)
Relationship to the deceased --
Name of Funeral Florae -
IMPORTANT:
1 represent that to the best of my ivwwledge,the deceased(has)or rq maker,defibriNator or any other battery operated
dsvkc R in his or her body_ (Circa One)
I certify that I have full power and authorization to arrange for the cremation of the rematrts and to direct the disposition of the
cremated remains.that any Pomona,possessions have OMW been removed or may be destroyed,and agree to protect,defend and
saw harmless Pka View Crarriatorim from any and all dakns and demwds for loss or damages which may be made agdw by reason of connected with remotion said remains directed.whether such claims or re are or a riot wholly
groundless,false or trauduler t
(Address) _
( of Relative or l agal Representative)
Signed on this dater
Disposition of Cremated Remains
I hereby direct Pine View to dispose of the aerneted remains as follows:
Olher errangemerns-Plea"specify: I C�
If pulverization of cremated remains is requested,check here
Reviskxr:Ja wwy 1,2006