Brindzak, Andrew Pwlr .VIEW
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QVEET1SBl1RY CRSEMtATORIUM
(S18) 745.1476 (Sl8) .'4.477 i28pq
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TOWN OF QUEENSHURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium*
accordance with and subject to it in
the remains of: s Rules and Regulations to cremate
(Name)
(Sex)
\ / y
(Street) 7Cit
Y) (St e) ( ip Code)
on
who died �, `
v day of � ]� P�
at (. P/ 7-.q? .(Place) (Address) 2' l
Name and address of nearest living relative or name of person
authorizing cremation:
(Name)
(Address)
Relationship to the deceased. ), (
Name of Funeral Home l� �v (L Jtl9
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or
has no pacemaker in his or her body. (Circle One)
I certify that I have the 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
ground e , al or fraudulent.
i ,X-- Quo
(Witness) (Address
v �
(Sign re of Relati e or ell Rep. and Address)
Signed on this date: '' 7