Luyk, Herbert 2�Q�tik� Q
�JCER ROAD, QVF=1?NS6 CREMATORIUM
(S 18) 745,4476 (18) RK 128pq
77
� 1 Di
� r nera
rector
a . e 0 ! Crematl.on Cases+ i(,L.
TP � emation Started
e i
T ; reme � ion Completed
Container /
• L Orr ��i���
U vN"
sn
3ca
i
� � 1
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:
C`aP�f ems? t 4"V k
(Name -----
- (Sex)
(Street) y fe2 t5rq
(City) (S le) (Zip Code)
who died on A day of 20 01C7
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
Name ress - -
(Add
Relationship to the diets ztl�l -
Name of Funeral Home ZL��
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or has no pacemaker,defibrillator,battery,battery pads,power
cell,radioactive implant or radioactive device in his or her body.(Cir a ne)
I certify that I have full power and authorization to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,that any personal possessions have either been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View Crematorium from any and all claims and demands for loss or damages which may be made against them
by reason of or connected with the cremation of said remains as directed,whether such claims or demands are or are not wholly
groundless,false or fraudulent.
(witness) r (Address)
(Signature and Addr s of Relative :or Re r l esentative)
Signed on this date: C��i+� 3� ,zOG7l
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 1,2009