Tuttle, William To 0 QU �8
PwE ti''(EW ��� ���
CEMETERY AND CREMATORIUM
����� ROAD, Ql1E�N39URY, NEw YORK 128p4
(518) 745.4476 (518) 745••4.477
FQneral Director �^
�' dme ( iC(lll2
Cases+ J��)
^d '• e C! Crema t l.on ��`�wac( �U
Te remation Started
Cremation P
Com leted 3, 2 �
%e c ( Con alner
I
LC
I
I
I
I
I
Town of Queensbury
Pine Yew Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office:(518)745-4476,Crematorium: (518)745-4477
Authorization to Cremate
to its Rules and Regulations to
The undersigned requests and s►rttrorizes Pine View Crematorium,in accord >ce ar with and subject
cremate the remains of:
SOX
(Name) (3 03
( ) (any) ( ) ,uP%,we)
day 20�
who died on _
at (Place) (Address)
Name and address of nearest
Nvirig relative or name of person euthorizing cremation:
C6 �rZ�
(Name) (Address)
Relationship to the deceased ---
Name of Funeral Home M. B. Kilmer Funeral Home
IMPORTANT: d(has) (has no) .deiiiA wor,battery,battery Palk.Power
I represent that to the best of my bwMedge,the deceased
call,radioactive implant or radioactive daubs;in his or her body.
I certify that I have full power and aulhorWdlon to avenge cremation of the remains and to dithe rect the disposition L the
io removed or may be destroyed,and ague to Protect,defend and
cremated remains,that any Personal possessions have either been
save harmless Pine View Crematorium from any and all and demands for loss or damages vfiidt maybe made against them
by reason of or connected with the cremation of said remains as directed,whather such claims or demands are or are not w mAY
groundless,false or fraudulent.
-------------
( (Address)
(Signature and Address of ReWvve or Legal Rom)
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 Spew. j
if pulverization of cremated remains is requested,check here
Revision:January 1,2009