Barber, Horace E Ofral -/
PINE PINE CREMATORIUM, INC.
Quaker Road, Glens Falls, NY 12801
CREMATORIUM,INC.1 Phone (518) 798-4726 or if no answer 792-1114
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine Crematorium, Inc. in accordance with and subject to its Rules and
Regulations to cremate the remains of:
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(NAME) �Q/J v l c (SEX)
��i s•!C%C'�sr �S 2-/ /. -geY
(STREET) / (CITY) (STATE) (ZIP CODE)
who died on /.? day of 19 a'
at aiG /2, 2 �! �i,.� / r r`'
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
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(NAME) % (ADDRESS)
Relationship to the deceased 7 — •
Name of funeral home Ag-7-z:e t-di
IMPORTANT: I represent that to the best of my knowledge, the deceased has or '.o�acemaker in his or
her body. (CIRCLE ONE).
I certify that I have the 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 Crematorium, Inc. from any and all claims and demands for
loss or damages which may be made against them by reason of, or connected with,the cremation of said remains as
directed, whethe such claims or demands are, or are not, wholly groun less, false or fr udulent.
(WITNESS) IGNATURE OF RELATIVE OR LEGAL REP.)
7 t d icit, y Azko, .I,, ,r C.... -
(ADDRESS) (ADDRESS)
Signed on this date ;2'2"1- /3 / i'
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine Crematorium, Inc. to dispose of the cremated remains as follows:
Mail to ip.44.41,79
Other arrangements - please specify:
If pulverization of cremated remains is requested, check here: