Goodsell, Donald OF - QUEE
L1YE VTE'W CEMETERY AND CREMA 1'.�'./
QUAKER ROAD, QUEENSBURY TORIUM
(518) 745-4476 (51' NEW PORK t284a
8) 745-4477
.. ................ ..... Funeral -Director
.....................00 Case #_
Date of Cremation
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Time Cremation Started
Time Cremation Completed
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Type of Container I/n
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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 authortrm Pine View Crematorium,in accordance with and subject to Its Rules and Regulations to
cremate the remains of:
(Name) (Sex)
( ) (CMr) state) (zlp code)
who died on day of �� , zo 0 q
at �� / 2 eo t
mom) (Address) —
rrat and address of nearest living relative or me of person auttrortzirrg cremation:
Memo) (Address)
Reletiorvftp to the deoeesed f —
Name of Fumral Nome YAP4
IMPORTANT-
I represent that to the beat of my WwMedge,the deceased(tes)or p er,defibrlilator,battery,battery pa*power
cell,radioactive lmplant or radioactive device In his or her body.( )
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 Cremetorhm from any and ail claims aril demands for loss or damages which may be made against them
by reason of or connected ed with the cremator of said rerrraina as directed,whWw such dalms or demands are or are not wholly
lei,false or iraudutent.
( )
(Signature and Address of Relative or Legal Representative)
Signed on this date: /W.i s 0
Disposition of Cremated Remains
1 hereby direct Pine View Crematorium ium to dispose of the meted remains as follows:
Mai to
Oliver arrangements-Planes spedfy:
If puivertzation of cremated remains is mWeeted,check here
Revision:January 1,2009