Howland, Jonathan rrn74N OF QUEEVBU9KY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director Sfc,ffvrt/�
Name �Onejho� owla„� Case # �1S
Date of Cremation ,Ting Z001
Time Cremation Started ' S() ' !n
Time Cremation Completed
Type of Container n arj
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 undersigned requests and authorizes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of-
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(Name) (sex)
(Street) (City) (State) Code)
who died on day of C5 C7
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(Place) (Add )
Name and address of nearest living relate or name oTpeison au�orjzing crer�ia�ori:— — — — --
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(Name) (Address)
Relationship to the deceased
Name of Funeral Home �� ��e� Aw '.•,/ AJ1't2Z I
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has) (has no) maker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her body.
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 personal possessions have either been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View Crematorium a all claims and demands for loss or damages which may be made against them
by reason of or with of remains as directed,whether such claims or demands are or are not wholly
groundless,fa or
( )
( ature and of Relative or Legal Representative)
Signed on this date: 7/�
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to RC A '9 y='
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
Revision:January 1,2009