Will, Dorothy (7'l-I T�N OF.. QUEEN5BU_r, y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director c�
Name o�o�L W
Case #
Date of Cremation 5 ZZ
Time Cremation Started k
Time Cremation Completed UU AA
Type of Container Frc' r� owtr s j
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:
Dory -/-A y /(/ All L 111C-
(Name) �a (Sex)
/3- QuIFa7 �,una. �e QuceIVS6urS Ay
(Street) (City) (State) (zip Code)
EP
who died on j h day of T .r3 E 20 U 9
at GL E/V_S Fig L L S yo s P/TA L /,f:tA9.ee—
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation: /
C&O � w�CLr Qd��87��� ' lQ Sirr�c ,a� C�g
(Name) (Address)
Relationship to the deceased 5 6 V17
Name of Funeral Home
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)o (has no) aker,defibrillator,battery,battery pack,power
cell,radioactive Implant or radioactive device In his or her body.(C a One
I certify that I h full power and authorization to arrange for the cremation of the remains and to direct the disposition of the
cremated re s,that any personal possessions have either been removed or may be destroyed,and agree to protect,defend and
save harm Pine Viewf* t
t m m any an all claims and demands for loss or damages which may be made against them
by reason connecte a so remains as directed,whether such claims or demands are or are not wholly
ground I fraud
o
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(Address)
N 117� 3
(Signatu a and Address of Relative or Legal Representative)
Signed on this date:�6
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
Revision:January 1,2009