Swanson, William 1 '
rrnWN OF QUEENSBWKY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
C Funeral Director
Name � ,�I,tir, `�wi��5u Case #
Date of Cremation
Time Cremation Started 1Ib ph
Time Cremation Completed 3 ly Ph
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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 subject to its Rules and Regulations to
cremate the remains of:
(Name) (Sax)
y F7,1))c rL.� (-1 . _ 3 :sc- —�V
(Street) (City) (State) (L�P+� )
who died on
day of 20_
at (Place) (Address)
Name and address of nearest living relative or name of parson authorizing cremation:
(Name) (Address)
Relationship to the deceased
Name of Funeral Home
IMPORTANT: has r has no maker,defibrillator,battery,battery pack,power
I represent that to the best of my knowledge.the deceased( ( )
cell,radioactive implant or radioactive device In his or her body.(Cr
1 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 personei ass ns hav her been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View um from any and al alms and demands for loss or damages which may be made against them
by reason of or the crematton of saJd remains as directed,whether such claims or demands are or are not wholly
groundless,fat
(Address)
r
C,14 et�
(SIgnatft and Address of Relative or Legal Representative)
Sign
ed on this date:
Dispositlon of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:
If pulverization of cremated remains Is requested,check here i
vision:Janus 1
Re ry ,2009
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