Goodman, Philip D Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury,New York, 12804
Cemetery Office:(518)745-4476.Crerttatofiurm.(518)745.4477
Authorization to Cremate
The undersigned eats tali ate F'gteView Cam.ataccontance nitt end sibtect to its Roles and Reguiations to
cremate the remains of:
Philip D. Goodman Male
(Name) (sex)
(Street) (city) (State) (Zip Code)
who died on 29th dayd December 20 07
Tri-County Nursing and Rehabilitation Center
(Place) (Address)
Name and address of nearest hying relative or rare of person authorizing cremation:
Philip Goodman 664 Goodman Rd. Johnsburg, NY
O O
Relationship to the deceased S o n
NanstO uneralHonte Alexander Funeral Home, North River NY
IMPORTANT:
rrepresent that to the best of my knowledge.the deceased(Etas)or(has no)pacemaker defibr ,or,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her body.(Cede One)
I certify that I have kit power and molt to arrange for the cremation of the itinerbics and to(Erect the ftposillon of the
cremated remains,that any personal paw tone ems!!been:-toted ar wa►to destroyed.and agree to t iedt,defend and
1.
.__ ==' _'- r.-=7 tzx- be made at them
v r :s �� ti ,�s.0 r rags or!Swum liar are or are not wholly
_ (. LC—USO
- ,v 735 FSf (Zs')L twS3u. 't.(/ /223V3
{ and Address /F Relative or regal Representative)
Sired on this dads 1 C
y L Disposition of
Cremated Remains
I hereby Pine•l Crematorium to d�e of the cremated remains as fellows::
Mart to
Other arrangernents_Please Funeral Home will pick up
If puirer¢ation of cremated remains is requested,check here
Revision:April 18,2007