Deneen, Daniel TO
0 QUEE9�,(523UTT
PIN
CeMrTtRy AND CREMATOR
ROAD, QUEENSBURY IUM
(518) 745•4476 (518MEW YORK 128p4
) 745'•4477
• Funeral Director
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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 Pkw View Cmmftriurn,in accordance with and subject to Its Rules and Regulations to
cremate the remains of:
PA44 i e
(Name) (sex)
(street) (CtY) (State) (Zip Code)
who died on s i X r h day of r�b Yu r Y 20 0
at �� WurS {orJ (t )Nsbg�ew�'oFk(�-�a
( )
Name and address of nearest imm relative or name of person s axtizi ng cremation:
1Lve iDONeeN '!�' R or tom- aIrNsr15;NS,�
(Nam) (Address)
Relationship to the deceased
Name of Funeral Home KA,�LNR�'d A-3k�lr
IMPORTANT:
I represent that to the best of my iotowledge,the deceased(has) (tree paoedrraker, l po
wer
cell,ra Ive implant or radioactive device In or her body.( )
I certify that I have full power and auftwb adon to arrange for the cremation of the remains and to direct the deposition of the
cremated remains,to any personal possessions have ether been removed or may be destroyed,and agree to protect,defend and
save harmless Pine view Crematorkon from any and aM and demands for loss or denreges which may be made against them
by reason of or connacted white the cremation of said remains as d mciad.whether such cheirrs or demands are or are not wholly
groundless,false or fiaudkrient.
(1►Vtrness) ( )
( �d of Relative or Legal Represerftd*
Signed on this dater
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Plssse spediy:
If pulverization of crerrnated remains is requested,duKk here
Revision:April 18,200