Birsett, Victoria f
i
O� OF. QUEE BU
-r�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
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Name
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Date of Cremation 0"'i4yr si lw�
Time Cremation Started ;pp 'OH
Time Cremation Completed 3'jb O
Type of Container
Remarks :
N is► � � _ �
Z 70
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s Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12804
i Cemetery Office: (518) 745-4476, Crematorium: (518) 745-4477
a
Authorization to Cremate
The undersigned requests and authorizes Pine View Crematorium,in accordance with and subject to Its Rules and Regulations to
cre�matte the remains of: i _
Y (Na ) (Sex)
1,, A,, 3 r
(Su t) _ (City) (State) (zip Code)
who died on day ooff - 200
(Place) (Address)
N me and address of nearest living relative or name of person ahorWngcremation:
0x0(Z.
(Name i(Address) r
Relationship to the deceased
Name of Funeral Horne
IMPORTANT:
I represent that to the hest of my lawMedge,the deceased(has)orl no)pacemaker defibrillator or arty other battery operated
device In his or her body. (Circle One)
I certify that I have full power and authorb ation to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,that any personal possesslons have either been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View Crematorium from any and all claims and demands for loss or damages which may be made against them
by reason of or connected with the cremation of said remains as directed,whether such claims or demands are or are not wholly
round rauxiulent.
PoS#-t 7 A7-
( natur %nd ress of Rela a or Legal Repr tative) it
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-Pleese specify.
If pulverization of cremated remains is requested,check here
Revision:January 1,2006