Linck, Nathan TO O
B c_1 PLNE PIER CEM
ROAD, C?V �NSg ANp CREMATORCU
(518) 745.4-416 �Y' NEw YORK i2soa
Funeral DirectorINJiLl
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me Cremation St 700
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T : me Cremation Completed f % . �'
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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 autwrtws Pine View CremalorNun,in accordance with and subject to its Rules and Regulatlons to
cremate the rprpft
of..
(Name) (Sex) X r j
(fit) (city) (state) (Z p Code)
who died on d day y�G�} 20_C)_J�
at L`V bs
(Place) ( )
Name and address of nearest 7-/ ewtive or name of crenumon:
"J �) 7E
(Name) (Address)
Relationship to the deceased A0 T- -
Ne of Funwd Homey././`'!j
me
IMPORTANT: /
I represent oral to the best of my Wwwledge,the deceased(has)w
oemaker,deflfxaator,battery,battery peck.Power
call,radioactive implant or radioactive device in his or her body.(Coda ne)
i certify that f have fA power and authorkotion to anartge for the crernaftt of the remains and to died the disposition of the
cremated remelts,that any 1p, w tei poeseasiutas have enter been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View tkarrteWwn from any and aill A i and derrtards for loss or ftneges whidt may be made against them
by reason of or oortrte rl a wffft tic a a ail a t of add remains as I what w such claims or demands are or are not wholy
false fraudulent. �o ,
and Address of Relative owr Legal )
l
Signed on this date:
Disposition of Cremated Remalre
I hereby died Pine View O ntetorlurn to dispose of the cremated remelts as Mow
Mad to
Other arrangements'Please spedfy:
t puN 03don of c ramalad remaits is mewled,dxwl here
Revision.April 18,2007