Green, Travon TOTVN OF QUEENs5BURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director &4A
Name f r t cx-; &'C-m Case #
Date of Cremation L dd,3
Time Cremation Started .5 �F111 rf-*N
Time Cremation Completed ��• WJ�f(1
Type of Container fn�"��"` 1, l� b0r-� rot)- tL
Remarks :
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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 wwwsigned requests and aiNrortws Pine View Crematonkxnn,in accordance with and to Its Rules and Reputations to
cremate the remains of:
vo 2
(Name) (Sex)
12, y
O / (City) (State (23P )
who died l9 day of ..! 200 J
at
(Place) O
Name and d nearest relatIve or name of person at
p
( ) ( )
Relationship to the deceased
,��
Name of Funeral Home
c �1 _I� L-� • J jG
IMPORTANT:
I represent that to the best of my iawwledge,the deceased(has)or Q=no)Pacemaker,dafibnrffeWr,battery,battery per.power
oeN,radioactive implant or radtoec dve device in his or her body.(Circle One)
I cEx* I have*A Power and aulhoriz�on to arrange for ffte cremation of the remains and to direct the disposition of the
cremated that any Personal possessions how either been removed or may be destroyed.and agree to protect,defend and
save Pine View crematakm from any and al claims and derrrentds for k=or damages which may fee made against Own
by or connected with the cremation of said as directed. such deice or demands are or are not whey
lreudurlent.
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Witness)
jkddr�
f 11U �L J �09�
(Signmhxe and Address of or Legal R
Signed on this date: ( �/:)
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 pdvertzabon of cremated remains is requested,check here
Revision:April 18,2007