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��hxF�t ROAD, QVB?NS9URY
(518) 745.4-476 KEW YORK 176,
(518) 745"4477
Funeral Director
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Town of Queensbury
Pine Yew 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:
G-�2AC� ZERT0L0-rrk IF ,rnRLE,
(Name) (sex)
(Street) // (City) tste) (Zip Code)
who died on to day of 2001
at 1 u
(Place) (Address)
Name and address of rarest living relative or name of meson O,FbUiE LERTDLQ-16 aO CA%RfEi_JR CiRC.tELIleetASBaetA .ncy ia$ jC�
(Name) (Address)
Relationship to the deceased AU SR A tLP
Name of Funeral Home �S�e o
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has) (has no) er.defibrillator.battery,battery pack,power
Dell,radioactive implant or radioactive device in his or her body.( O
I certify that I have full power and authorization to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,that any I possessions have either been removed or may be destroyed,and agree to protect,defend and
save haffnlpds Pine V um from any and all claims and demands for loss or damages which may be made against them
by reason. nett cremation of said remains as directed,whether such claims or demands are or are not wholly
and or
�O tRCLE) QuEEtAS3uRc ;t)n
(3ip a and Address of Relative or Legal Representative)
Signed on this
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here 0
Revision:January 1,2009