Sherry, Robert W TOWN OF QUEENSBURY C1
PINE VIEW CEMETERY
I4
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
cremai the remains of: ,
�'�\)[2 h e f- V% Sit c VV
(Name) (Sex)
Pi3 i¼ r 1 ` "
(Street ) (City) (State) (Zip Code)
who died on ( / / day •
of 19
at ///S Helc'
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation :
Pe- L, C✓� a 6, c rr / PC 1 l 3 dcvex-Ll >
(Name) (Address)
Relationship to the deceased !�► ���
Name of Funeral Home S &//i ' ei1 l"1i 1 ri �cf �� f e'
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or
has no pacemaker 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 View Crematorium from any and all claims
and demands for loss or damages which may be made against them by
reason f or connected with the cremation of said remains as
direct , whether su h claims or demands are or are not wholly
grow ess, false r f a lent.
( fitness) (Address)
(Signature of Relativ or Legal Rep. and Address)
Signed on this date :