Valastro, Angelo (rO nN OF QUEENSBU9KY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director fh, )7FG12 — C)
Name 'AN&G,1,0 0isLvNt x-2,0 Case # Ll q- (."
Date of Cremation ZQ DLf
Time Cremation Started � ; *4 '- ,
Time Cremation Completed 16, AA
Type of Container 64<7-c) 6641_sr�6 LA, �11 �L.; ✓r-1
Remarks :
EN
TOWN OF QUEENSBURY 41
2
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 Regulations to cremate the remains of: ��
A N c 1 O `�(`(11 C NA E L \)A I CT(�n (SEX)1`1 ALE-
(NAME) t ,
(STREET) T (CITY) (STATE) (ZIP C E)
who died on day of b\)E:rn R E2 20_a�_
as �� L
(PLACE) (
at 4, F11C �L.IC �DDRE�SS) }�.
Name and address of nearest Irving relative or name of person authorizing cremation:
Relationship to deceased 1 'E,
Name of Funeral Hom c ' ,e.PC"-
IMPORTANT
I represent that to the best of my knowledge, the deceased has oKhas no cemaker in his or her
body. (CIRCLE ONE)
1 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
rdr-e matodum from any and all claims and demands for loss or damages which may be made
again em by reason of or connected with the cremation of said remains as directed,whether
such I or mands are or are not wholly groundless,false or fraudulent.
(ADDRESS)
J( (SIGNATURE OF RELATIVE ORA EGAL REP.AND ADDRESS)
Signed on this date: oil . �,�,� QO