Alden, Beverly -7 QU��
r�IAK-ER R b�C M�T E'R Y AND C R E M A T O R I U M
Ql1ELNSBtlRY� KEW YORK 178o4
(Sl8) 745.4476 OM 745'.4477
N ner8l 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 cxmdersigned requests and autltorines Pine View Crematorium,in accordance with and subject to Its Rules and Regulations to
cremate the remains of:
U��rl� �yrt4ce �lde�r F
(Name) (sex)
to Uis 1 A com, e
(city) �� -
pp Code)
2oS�L
who died on ID day ofat
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(Place) ( )
Name and address of nearest{wing relative or name of person atrthorizing cremation:
FF`P �^'_`1'��r PC G� I c�(�- CO u n` ' � �7'•,h�-I Z��
Relationship to the deceased /g u
Name of Funeral Home
IMrepresertt that to the best of my ivwwiedge,ft deceased(has)or(has no)pacemaker,deftillator,battery.Amy per,per j
can,radioactive in wtt or mdioective device in his or her body.(Circle One)
I ee rdfy that t have null power and mithortretion to arrange for the cremation of the remains end to direct the lion of the
cremated remains.trot any peraond poesasslons have either bean reproved or may be destroyed.and agree to probed,defend and
save harmless Pine View C emstorirm from any and 811 coins and demands for loss or rim g 1 1 which may be made against thorn
by reason of or connected with the cremation of said remains as di ecbd.whetter such deigns or demands are or are not wholly
groundless,false or
j-i n
(Signea"and Address of Relative or Legal Repressive)
Signed on this date: ?—o
Dispoekion of Cremated Remainn
I hereby direct Pine View Cremmorium to dispose of the cremated remains as follows:
Mail to
I
Other arrangements-Please specify-
If pulverization of cremated remains is requested.check here
Revision:April 18.2007