Sargent, Gerald L TOWN OF QUEENSBURY
PINE VIEW CEMETERY
, &
-' CREMATORIUM
• Quaker Road, Queensbury, New York 12804
Phone(518)Crematorium 745-4477(if no answer)
Cemetery 745-44.76
•
• AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in accordance with and subject
to its Rules and R ulations to cremate the remains of:
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( (SEX)
.
(STREET). 6 _K,Q0 sf IlisM-61
(CITY) . ,,--77 .5,-
(STATE) (ZIP CODE)
.)4
who died on
-- day of 20 4 ..t
at t c_ _ A ci : 0-t-- .
(PLACE) (ADDRES
•
Name and address of nearest living relative or name of person authorizing cremation:
11, &A GI h SG.A Y- •
Relationship to deceased(V
6 �
/„ '
Name of Funeral Home ji,,..4.1
IMPORTANT
I represent that to the best of my knowledge,the deceased as r has no .-.-maker 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 of or connected with the cremation of said remains as directed,whether
such claiz or demands re or are not wholly groundless,false or fraudulent. •
cfi •
TNESS) (ADDRESS)
i/. / i— d": /n .,/i -/--9-
(S TURE OF RELATIVE LEGAL REP.AND ADDRESS) •
Signed on this date: i c: 3 << :
(