Goodson, David _7 n ,
Pr.NE ti'-iE�Y CE QU �r�� �l
M�TERy AND CREMATORi
�l�•h.K_e.R ROAD, Q�LNSBURY, UM
(518) 745.4476 ( KEw PORK ►2804
Sl8) 745.•4477
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 undersigned requests and authorizes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
(Name) (Sex)
(Street) (City) _7 ( eT (crp Code)
who died on _ _ day of 20(2
at
2�
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
(Name) - (Address)
Relationship to the deceased
Name of Funeral Home
IMPORTANT: the dew(�)or aoemaker.defibrillator or any other battery operated
I represent that to the best of my gtowledge.
device in his or her body. (Circle One)
I certify that 1 have full power and ar# wbzfim b a�for sXetr�tior►of the remains and to direct the disposition of the
crenated rr ,that arty persorad pions hew ether been removed or may be destroyed,and agree to protecl,de(ertd and
aby reason� connected cremation said remains directed,whether such claims or demands are or are not whoilysave harmless Pka View Crematorltim ban any anid sit chow and denwWs for loss or rig P g: which MaY be against
groundless,false or fraudulent.
(w ) ( )
(Signature and of Relative or Legal Representative)
Signed on this date: '
02
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
Revision:January 1,2006