Brodell, David rrO`I N OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director A
9
Name Case #
Date of Cremation
Time Cremation Started
r r"
Time Cremation Completed
Type of Container C
Remarks :
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Town of Queensbury
Pine Yew Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office:(518)7454476,Crematorium: (518)745-4477
Authorization to Cremate
The undesigned requests and authorizes Pine View CramataNan,in accordance with and aqw to its Rules and Regulations to
cremate the remains of
(Name) (Sex)
(Street) (may) ) (7Jp Code)
Z- day of 20_,.-
who died on �
at rt l
( ) ( )
me and address of n7de
T(( .
ve or name of person
�l d ,3,. 311��a
( ) ( )
Relationship to the deceased
Name of Funeral Home
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has) (has no Pacemaker,delor.bury,battery Pad(,Powercell,radioactive implant or redloactive device in his or her body.( )
i certify that i have full power and aulhorb adon to arrange for the cremationon of the remains and to direct the disposition of the
crenated rernairrs.that any personal possessions have either been removed or may be destroyed,and agree to prolect,defend and
save harmless Pine View Crernatorkhsn from any and al claims and demands for loss or damages which may be made against then
by reason of or oonnacted with the cremation of said remains as directed.whether such cta'Rms or demands are or we not wholly
groundless.few or fraudulent
C'
( and Acidness of Relative ty legal Representative)
Signed on this date: 4 "
Disposition of(wed Remains
hereby direct pina Viewh,CremeWrium to dispm of the cremated remains as follows:
Mail to
Other amanpements-Please specify:
If pulverization of cremated remains is requested,check here
Revision:April 18,2007