Loucks, M. Patricia �v UE B U .
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
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Casa #
Date of Cremation
Time Cremation Started n
Time Cremation Completed 3 ; ? S,
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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 C.rematorlum,In accordance with and subject to Its Rules and Regulations to
cremate the rre^t/m , I c� � �n
11
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(Name) ( )
(Street) (city) (Stye) (Zia
who died on GP day of d il 20_a_j7
att�
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Name and addres-4 of nearest living relative or creme of
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(Name) (Address)
Relationship to the deceased �S
Name of Funeral Home C
IMPORTANT. �.t�/t0 oo
I represent that to the best of my knowledge,the deoM (hes no)peoemaker,deflbrillaW.battery.battery pack,power
cep.radioactive implant or radioactive device In his or her (Circle One)
I cw*that 1 hence fun power and auowriz uw to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,that any peremet possessions have either bean removed or may be destroyed.and agree to protect,defend and..
save hemless pine View Crenetoricmm►from any and all claims and demands for loss or damages vrhich may be made against them
by reason of or connected with the cremation of7Z6
as such claims or demands are or are not wholly
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K ) ( )
l '
(Signature and Address of r Legal Representative)
Signed on this date: `v
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as f IkMs:
Mail to
Other arrarrgerne is-Please specify:
If pulverization of cremated remains is requested,check here
RsvWm:January 1,2009