Fuller, Ida I'UWN U1= QUEENSUURY
a {31NE VIEW CEMETERY
LiEhl1TUZ 1 UN
Quaker Road, Queensbury, New York 12804
Phone (510) Crematorium 745-4477 or il' no answer
Cemetery 745-4476
AU'nion i zAT I ON TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
cremate thhe , Y`a111:71ins UF :
(IVarllo ) (�ie/c )
Q wLC�
(Street ) (City) (Skapk e) ( Zip Code)
who died on day of 000
(Place) T (Address )
Name and address of nearest living relative or " n'abre.of per-sun
authorizing cremation :
( am ) (Address)
Relationship to the deceased
Name of Funeral Home
JAIMUKTANT:
�I r*_P_r sent that to the best of my knowledge, the d:e;c,ea;se0,, hAk oar
has no acemaker in his or her body. (C•ircle One).
I certify that I have the full power and •aut:horization to arrange
for the cremation of the remains and to direct. the di,s;po,si-aion of
the cremated remains, that any personal possessions have either
been removed or may be destroyed, and agree to protect, de "..Pnd
and save harmless Pine View Crematorium from any and all claims
and demands for loss or damages which may be made against them by
reason of or connected with the cremat:lan of said remains as
directed, whether such claims or demands are or are not wholly
groundless, false or fraudulent .
(Witness ) (Address )
(Signature o lative or egal Rep. and Address)
Signed on this da e : 2