Jackson, Joyce QU E E
�h3CpR ROAD,MTERY ANp CREMATORIUM
QUEENgSaVRY, NEW YORK 12804(518) 745.4,476 (518) 745.,4477
Funeral Director
Cremation C a s e i+
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Cremation Completed
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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 autwrfzes Pine View Creaatokm,in accordance with and subject to its Rules and Regulations to
cremate thef
( remains o _
J b` C[•-
Sex
(street) (City) ( ) gy)
who died on 1 141- day of L Z0 0-
9
at
(place) O
Name andr6U
of nearest living relative or name of person autivormng cremation:
L i'J Gf3/j .—
(Name) (��)
Relationship to the deceased 4 l
Name of Funeral Home—,A-!)
y
IMPORTANT: /
I represent that to the best of my knowledge,the deceased(has)or;' tag rgeoamaker.defibritletor,beaerY.battery Peck.power
call,radioactive implant or redioac&ve device In his or her body.(Cir iTne)
I certify that I have fait power and autlrortzatim to arrange for tf re cremation of the remains and to direct the disposition of the
cremated remains.that any pWWW pogsesdons have either been removed or may be destroyed.and agree to protect,defend and
save harmless Pine View Cremaoorihm from any and Sit deims and demands for IOSS or rim rrrages MAhish may be made against them
by reason op vrhlh thhe aernation of said remains as d re krecied,whWw such claims or demands are or a not wholly
cy
-WY
I —V— (TOWLire and Address//o/Jf Relative or Legal )
Signed on this date: 01�` e
Disposition of Cremated Ramains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrarKpraMs-Please specify:
If pulverization of cremated remains is requested,check here
Revision:April 18.2007