Bailey, Elaine TO OF
PINE VIEW CE Qu
MTERY AND CREMATORIU
� R ROAD, Q(j-er qSBURY M
(518) 74S•4�76 KEW YOR}C 128P4
(518) 745'•4477
Funeral Director
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Town of Queensiwry
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 Crealatodum,In accordance with and subject to its Rules and Regulations to
cremate the remains of:
(Name) ( )
(Street) (may) (S (Zip Code)
who died on day off- 2it7 ' 20_bq
at
(Ply) I (Address)
Name and address of nearest living relative or name of person authorizing cremation: l
t�t1 -Q' -
(Name) ( )
Relationship to the deceased '
Name of Funeral Home�(Yt air
IMPORTANT:i represent the to the best of trry btowledge,the deceased(has) (has no alter,dWftftW.battery.battery Paac.Power
cell,radioactive implant or radioactive device in his or her body.
I oarti(y that I have full power and aeon fD NUNW for the aeon of the remains and to direct the dwosition of the
cremated remain;,that any personal pow have sOw been removed or may be destroyed.and agree to protect.defend and
save hanTdess Pine View Crematorium from BOW and al{ 'a+ms and demands for toss a daara8es wHch may be made 8901nSt them
by reason of or connected vAh the aema6on of said runs as domer.vbevw such dabs or demands are or are not vrhotly
groundless,false or fraudulent.
^7Wdne ) ,
(Signature and Address of R or Legal Representative)
Signed on this date: "
DWpawion of Cremated Remains
I hereby direct Pine View Crematorium to dispm of the cremated remains as follows:
Mail to
Other arrangements-Please spedly:
If pulmmton of cremated remains is requested,check here
Revision:April 18,2007