Foote, Dorothy To
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P W CEMlYTE�RY ,� �,r.�`� B l�l�. �J
ROAD CREMATORI
UM
(518) 7455 6 SBURY, NEW YORK I78,
(518) 745•.4477
_ Funeral Director__ j� ,
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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 Crematorkan,in accordance whh and vAlec:t to fts Rules and Regulations to
cremate remak s df:
(Name) O �7T-- - — T-U—
Sl}4 /Ivy U&�iiJ3 L`
eet (City) (fie) (zip )
(Stre
who died b day of 20_9;�—J
(Place) (AddfeSs)
Name rasa of living relative or names of person oxhodzing cremation:
(Name) )
Reletionship to the deceased eTl "—
Nam f
Name of Funeral Home
IMPORTANT:
I represent that to the best of my imowledge,the deceased(has)or(hes no)peosmalcer,daflWllator,be".battery Peck.Power
cell,radioactive implant or radioecth m device In his or her body-(Cide One)
I entity than I have*A power and suftrtaafion to arrange for the cremapon of the remains and to direct the disposiion of the
cremated rerneke,that any persorteh possessions have either been rerrnoved or may be destroyed.and agree to protect.defend and
save harmless Pine View CremekxUn bom any and aM deins and demands for bee or damages which may be made against them
by reason of or connected with the cremation of said remains as directed.Wheow such claims or demands are or are not wholly
(
(Suture and Address a Legal W )
Signed on this date `S'/� l d
Disposition of Cremated Remains
I hereby direct Pine View frerrratodum to dispose of the cremated remains as Mows:
Mail to
Oder arrangemerds-Plea"specify:
If pr*mftation of cremated remains is requested,check here
Revision:April 18,2007