Wanderer, Kurt PwE �Epsr c>✓ QUEE9q,5(3UT_T
Ml TERY AND CREMATORIU
L` 135%K�}z ROAD. QIJEF.NSgURY, M
(518) 745.4476 KEw YORK ►z80a
(S18) 745'•4477
Funeral Director V
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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 aulhortws Pine View Cremetorirxrt,In accordance wM and subject to its Rules and Regulations to
cremate the remains of. Aj
(Name) (Sex)
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Street) (City) (state) p )/
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(Place)
Name and address or nearest living r`eWm or 7,--,-Ofpersw
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(Nam)
Relationship to the deceased
Name of Funeral Home
IMPORTANT:
I represent that to the beat ofdevice
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dy.(or(hale One)
,d�ri�tor,battery,battery Pam•Per
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or 1 certify that I have f1A power and N*wrtwdon to anartge lir the cremation of the remains and to direct the dbposftn of the
ma
creted renv ins,that possessions have either been removed or may be desbvyed.and agree to protect,defend and
save harmless Pine netaiu any and r,n, ,and demands for loss or damages which maybe made them
by reason of or remains as directed, such claims or demtarxis are or are rat wholly
groundless,false or
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(Signatureand Relative or legal Represeritive)
signed on this date:
i
Disposition of Cremated Remains
I hereby direct Pine View Cremat dun to dispose of the cremated remains as fellows:
Mail to
Other arrangements'Please spew-
If pulverization of aerroled remain is requested,Crack here
Revision:April 18,2007