Mali, Anita To
PrLTN, VIEW CEM L�� `� u,
t7��KPR RO%�D Al M CREMATORIUM
QIIEENS9tlRY, NEW YORK 17604
(518) 745,4476 (518) 745'.4477
jFuneral Director
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Ceemati.on
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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:
P>7 ' ,- mom-
(Name) (sex) •�,�
(City)
Rip Code)
(Street) <J
day of b�� 20-P-J
who died on11
at 0 12 M (Address)
(Place)
Name and address of nearest living relative or name of person authorizing cremation:
(Name)
(Address)
Relationship to the deceased
Name of Funeral Home
IMPORTANT: has o has no maker,defibrillator,battery,battery pads,power
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I represent that to the best of my knowledge,the deceased( ) ( )
cell,radioactive implant or radioactive device in his or her body.(Ci
direct the
I certify that I have full power and authorization to arrange
have eitherthbeenemation of removed orhe remains and may be destroyed,and agree t disposition oect,f the
defend and
cremated remains,that any personal possessions damagesims ay cost them
save harmless Pine Vied with the cremation of said rema Crematorium from any and all ins as directed,whether such nd demands for k)ss or laims or demands are or are no wholly
by reason of or conned
groundless,false or fraudulent.
(Address)
ignatur n Address of Relative or Legal Representative)
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Signed this date: O
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Disposition of Cremated Remains
View Crematorium to dispose of the cremated remains as follows:
I hereby direct Pine �
Mail to
Other arrangements-Please specify: — -— --------------——
If pulverization of cremated remains is requested,check here
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Revision:January 1,2009
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