Bryan, Joan �O O
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(Sl$) 7'4Q4 6"VR;' NEW YORK 17804
8) 745,4477
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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 arMoftes Pine View Cvernsiorkan,in accordance with and subject to Its Rules and Regctatkns to
cremate the remains of: _
(Name) (�)
7 _r I' d W64,Al. t> Z
Sheet) (may) (State) ("Lip Code)
who died on ;z ' - day Vtb- 20jeY-
(Place) ( )
Name and address of nearest living relative or name of person authorizing cremation:
Relationship to the deceased
Name of Funeral dome
IMPORTANT:
I represent dug to the beat of my ivnowledge,the deceased(ties)or(Ines no)pacemaker,deMxSBW.battery,battery per,Power
cell,radioactive h4ft t or radioactive device In his or her body.(Ckde One)
i oertify that I have full pourer and adhorizatiort to arrange for the carnation 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 prate«,defend and
Phe View CremaNjum from save -or connected crernadon� dmMd.wheow su lowch daims or dovagesdemands dch are oram not w against groundWit holly
by
false or
(Address)
(Signatue and t;:::�lative or Legal Representative)
Signed on this date:
Disposition of Quyvacad Remains
I hereby drect Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:
It pAvertwbw of cremated remains is requested,check here
Revision:April 18,2007