Zack, Peter Sr. rrO O
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ROAD �TER�4 Y AND CREM^TORIUM�
(518) 7454 6 S9URY' KEW YORK l7sQ4
(518) 745'.4477
Flneral Oire
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Te cremation Started
^� : remdtton 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
Autimrization to Cremate
The undersigned requests and authorizes Pine View Crematorium,in accordance with and subject to Its Rules and Regulations to
cremate airs of
— (Name) (sex)
Street (City) (state) (Zip Code) /
who died day of
at I -Z "YL— n
lace ( )
Name of nearest living relative or name of
/,�
(Name) (Address
Relationship to the deceased (, !�J 1 fr V�
Now of Funeral Home / �BIG6� r`U•�!� /V�/7!� Q ��, !U%
IMPORTANT: no) maker.detkxi0ator,battery.battery pack,Power
I represent that to the best of my Imowledpe,the deceased(has)
cell,radioactive implant or radioactive device in his or her body(
Ire at that 1 have full power and authorization a>�thw been removed or may be destroyed.and agree Protect,defend and.
he cremation of the remains and to direct the disposition of the
cremated remain,that any persanat potion
save harmless Pine View Crametorirmr from any and all cairns and demands for loss
such claim or demands are or ore not wholly
m
by reason of or connected with the cremation of said remain as
ground or
ilUli
'i
(soma" of Relative or Legal R )
signed on this date: SZ-6` 6
Disposition of Cremated Remains
I hereby dked Pkre View Crematorium to dispose of the cremated remains as ROO".
Mail to
Other arrangements-Please SPecify:
If pulverization of cremated remains is requested,check here
Revision:January 1,2DO9