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Balfour, Maureen Qu tz CRE MATORIU7 EW CEMTERY AimP11"I ROAD Q(JEUU{S9l1RY, M (S18) 745.4476 NE YORK i2soa (S18) 745.4.477 � am� /� Funeral Director Crematl.on Casey 1 rrema � ion U Y StartCf ed CII. 1S • Te : remetI on Completed Container 11 V� IC �= Town of Queensbury Pine View Cemetery and Crematorium 21 C maker Road,Queensbury,New York, 12804 Cemetery Offi©e:(518)7454476,Crematorium:(518)745.4477 Authorization to Cremate The undersigned requests and authorizes Pine View Crematorium.in accordance with and subject to its Rules and Regulations to cremate the remains at (Nam) - ) S� (Stree�t),,� (City) (State) (Zip Code) who died on day of 20— CIA at Af �i� (per) (Address) and address of nearest MV relative or narne of person a Mwrt*V aentation: (Name) ( ) Relationship to the deceased 71 Name of Funeral Monter-7 LC i IMPORTANT: �: , I represent that to the best of my iaiowledge,the deceased(has) no d�ibriilator,battery,battery-P P cell,radioactive implant or radioactive device In his or her body.(� I cm*Out I have full power and auawrizelion ID arrange for an aemedon al!"remains and to A rl the disposition of the crenv"d remainm that any perac possessions hove~been rernoved or may be destroyed,and agree to protect,defend and save harmhm Pine Vann Cremebrium from any and a8 dams and derrtartds for bas or derrrepes which wW be made agarrst them by reesgt of or cornecled with ft aemelion of said FOOD"as dlrecled.wlrallim such deims or demands are or are not whotty false or ark 00 ) ( ) Signature arrd of Relative 00L ") Signed on tit data. Disposition of Cremated Remains I hereby direct Pine View Cremetmium to dispose of the cremated remains as follows: Man to other arrangements-Please spedifY: If pulverization of cremated remains is requested.Check here Revision:April 18,2007