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Daniels, Whitman
2"O O . PWE YTEW QUEErV5EUj�., 'C+t�'XkpR ROAD, CEMETERY AND CREMATOR QVEENSBl1RY, IUM (518) 745.gg7 �w YORK 12804 6 (518) 745'.4..477 Funeral Director Case ►+ ^ace Of Cremati.on t?L C ' •me Cremation Started 00 �h Time Cremation ComPleted 3 Tree of Container / I` - �e^arks t +c .� i,,, roI'9 � 5� h ------------- ----___ 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 unders%pad requests and auUwrfzes Fine View Crernatorkn.in accordance with and sulrj d to Its Rules and Regulati"to cremate the f:renv*vs o '' (Name) ( t via nit?�� (sveet) (City) (State) Rip Code) who died on 22 day of /C- 20 U at (per) (Address) Name and address of Iiving relative or named authorizn9 aemation: (fie) (Addre�) Relatior>9hip to the decease d S©� /7 Name of Funeral Home / t 1� L� v�J L er IMPORTANT: I represent that to the best of my ivgwledga,the dew Ned ) ea no) oemd .�, Y. 'Pow can,radioac live implant or radioactive device in his or her body. I certify that 1 have U power and aultori w*m to arrange far the cremation d the remakhs and to direct the disposition of the a mnated rarnam%that any personal possessions have either been removed or may be destroyed,and agree W prolec L delerhd and save Pine View C remelorium from any and all debts and demands for loss or damages which may be made against there by or conrrhecled with the cremation d said ramabs as drecled.whet her such deims or denwds are or are not wholly O ( Reb*m or legal ) Signed on this date: Z 7 b Disposition of Cremated Remains I hereby direct Pine View owwwrium to dispose of the cremated remains as foNows: Mail to Other arrangements-Please spoor If pulverization of awwlad rarrrains is requested,check here Revision:April 18,2007