Edwards, Anna Z� OF- QUEE9\�5BU-r
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW Y.ORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name
Case #
Date of Cremation
Time Cremation Started
Time Cremation Completed /4;1�7 66
Type of Container
Remarks ;
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 auftariaes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
V.
(Name) (SOX)
(Street) City) ( ) (Zip Code)
who died on 16 4w of D ��
at
(per) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
P.ew"M,arqV-VA. & 64tV aV . 1�8� y
( )
Rel edorns1hip to the me dece -ed n q
Na of Funeral i bme\as rn(3t.� y-
IMPORTANT:
I represent that to the best of my bwwledge,the deceased(has) (has no))acenvalter,de8brnlator,battery,battery pack.power
call,radlowMve implant or radioactive device in his or her body.
I certify that I have full powar and aulivorbstion to arrange for the cremation of the remains and to drect 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 from any and an claims and demands for loss or damages which may be made against them
by reason of or connected with the cremation of sell remains as directed,whetlrer such claims or demands are or are not wholly
groundless,false or fraudulent.
(vvnnese) (
(Signature annd Address of RelaWe cr l egal R
Signed on this data. dU -49
Disposition of Cremated Remains
I hereby direct Pine view Crematorium to dispose of the Cremated remains as follows:
Man to
Other wangemwft-Please spow.
if pulverization of cremated remains Is requested.check here
Revision:January 1,2DO9