Varney, Arthur �O O ,
PWE ti'TER! C1r QU E9�SB
Y AND CREMATORIUM��
ROAD, QliBL'NS9lJRY
(518) 745. �w YORK
4476 128Q4
(518) 745.-4-477
ry ( Funeral Director (�"r
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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
The undwWgned requests and authorises Pine View Crematorlum,In aomrdence with and subject to Its Rues and Regulations to
cremate the remains of:
Arthur Lee Varney M
(Name) (Sex)
20 Valley View Way Hebron NY 12865-
(SVeet) (CRY) (State) (ZJp Code)
who died on 28th day of February 20 9
at Albany Medical Center Albany NY
(Place) (Address)
Name and address of nearest living rete&m or name of person sudxwb ng cremation:
Brenda Varney 20 Valley View Way, Hebron, NY
(Name) (Address)
Relationship to the deceased Wife
Norm d Funeral Home Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to the best Of My larowledge,the deceased(has)or(has no)pacemaker,detw9ator,bellery.battery peck,pa*w
cell.redloeotiive impio t or redoective device in his or her body.(Ckde One)
1 ceritfy ova I have full power and au&arbstlon b arrange for the avmedon of the remake and to direct the deposition of the
cremated remains.,that any personal possessions have Gila i,een removed or maybe deshvied,and agree to protect,defend and
save harmless Pkw View CremehxWrn fiom any and all ceirtts and demands for loss or damages rrhleh may be made agoind own
by of a connected with ttne cremation of said remains as dkecled.whedw much deirns or demands are or are not wholly
ar Nmrdtrlerri
68 Main Street, Hudson Falls, NY
(Witness) (Address)
r . 1 20 Valley View Way Hebron, NY
(Signature Address of Relative or legal RepreaBrntative)
Signed ors this date: 31 (- )O
Disposition of C.tami ted Remains
I hereby d rect Pine View Crematorium to die me of the cremated remains 89 follows'-
Mail to
Other arrangements-Please specify:
If puNe tzation of Cremated remains is requested,check here XX
Revision:April 18,2007