Hoffman, Bruce %._/ NN OF:-
QUEE%/ 5BUr�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEHNSBURY NEW Y.ORK 12844
(518) 745-4476 (518) 745-4477
Name � 1J1 / Funeral Director
Case N
Date of Cremation (10 Z00
Time Cremation Started
Time Cremation Completed Ph
Type of Container �rC
Remarks : 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 Crematorium,in accordance with and sub)ect to its Rules and Regulations to
cremate the remains of:
(Name) (SOX)
(Street) (City) (State) (Zip Code)
who dlon JLV!� day of '"� 20_n
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
ej/V)11ct W 11&0-Y)
(Name) I (Address)
Relationship to the deceased `
Name of Funeral Home �h ailIMPORTANT:
I represent that to the best of my knowledge,the deceased(has) defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device In his or her body.(Cj�no))scemaker,
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 from any and all claims and demands for kiss or damages which may be made against them
by reescqof or connected with the cremation of said remains as directed,whether such claims or demands are or are not wholly
grou ,false ;frauduj".
(Address)
(Signature a Address of Relative or Legal Representative)
Signed on this date: Q 8, 069
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to '-
Other arrangements-Please specify: Zf,7 Z,
If pulverization of cremated remains is requested,check here
Revision:January 1,2009