Bailey, John s rO
P.rN YfEW CEM Ur
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'R ROAD TERY ANrD CREMATORIUM
(S 18) 745•4476 NTW YORK 17804
� am� Funeral Director
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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
ematuneder�signed rresquests and authorizes Pine View Crematorium,In accordance with and su
bject to Its Rules and Regulations to
(Name) 1 1
(Street) cc ' 3
(City) (State) 1
who died on (Zip Code)
i a day°f
at G�
(A z�1
ddress) -
Name and address of nearest living relative or name Of pen3ort au
thorizing cremation:
e� 1
CA
talc
(Name)
Relationship to the deceased l _�k
Name of Funeral home
IMPORTANT:
I represent that to the beet of my knowledge the deceased(has) has no maker,defibrillator,battery,haft
call,radioactive implant or radioactive device in his or her body.(Cir )
�'Pam,Pourer
I"'Y that I have U Power and authortmion to arrange
rrs cremated remains,that any personal �for the cremation of the remains and to direct the disposition save harmless pine Vie y CramatoriumPs all and dave either been emands Or may be destroyed,and of the
by reason i' or connected with the for loss or ��to protect,defend and
groundless,false or fraudulent. aematJon of said remains as directed,whether sum claims
sole rch mayre ormade against a not
re
(
ReDrI1.1 L'
(Signature and�ress of Reis or Legn
Signed on this date: 1 ' (\f—CV 'z c
Disposition of Cremated Remains
I hereby olrec Phre View Crematorium to dispose of the cremated remains as follows:
Mai to
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
Revision:April 18,2007