Hanser, Grete rro O
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PITI Vf EYV CEM Qu rE L �
��Ke3z RO^p �TERY AND CREM,,TORTU,
(518) 7,45�6 S9URY' KEw YORK 12804
(S18) 745"4.477
�n{! Funeral m
Director _
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Town of Queensbuiy
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 mq►nasts and outhiorizes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remakta of:
C tr =-I f_. H a,r s V-
(Name) (sex) ()l IIf
ct ,>se r
(Street) / City) (State) (lip Code)
who died on / day of! '0' 2—9
at 2 /S 5� (,� _S �V/f
(Place) (Addr )
Name and address of nearest living relative or name of person authorizing cremation:
(Name) (Address)
Relationship to the deceased 0-1 t I —t
Name of Funeral Home ko, I to A r h
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her body.(Circle One)
I certify that I have full power and authorization to arrange for the cremation of the remains and to direct the disposition of the
that cremated remains, at 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
grou less,false or fraudulent.
C c Y (Address)
itness) Kathuryn E. Green
Notary Pu":ic State of New York
IL Qualified in Schenectady County
(Signature and Address 6f Relative or Legal Representative) No.01 GR4872970
Commission Expires 12/2y/°�v/v
Signed on this date: � � �� �� ow
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to 1
Other arrangements-Pleese specify: AN71�� P" �f
If pulverization of cremated remains is requested,check here _
Revision:January 1,2009