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PINE Y(E W B C-1
CEMZTERY A�M CREMATORIUM
ROAD, Q(1Ep1ISBURY
(518) 745.4476 tYEw YORK 1z84a
(S18) 745'.4.477
Funeral Director a;- •�
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Oate 0( Cremation
Cremation Started its
Time Cremation Completed Z �1(;
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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 subjecl to its Rules and Regulations to
cremate the remains of:
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(Flame) (Sex)
(street) (City) (St" (Zip Code)
who died on i day of 20_0 Ct
at iF,NC �FAi_i_S sti7A1 _ 10• ihRP,LF-NS LDS- 11
(Place) (Address)
Name and address of nearest living relative or name of-person
e sc�wrizing crorriatiorr_ -- - — — -- —
(Name) C (Address) (J
Relationship to the deceased
Name of Funeral Home a
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has) (has no) maker,defibrillator,battery,battery peck,power
cell,radioactive implant or radioactive device in his or her body.(Cr
I c w*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
groundless,false or fraudulent.
(t 7) �`�` ��� ( ) l c, c- r Sty l lc aZAi'` �'
(Signature and Address of Relative orfAal Rep tative) �J
N yy5_
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:January 1,2009