Davis, Mary o`w OF- QUEE BU ,
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENggURY, NEW Y.ORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director_ B�EWr���
Name Mhr 3 Case #
Date of Cremation GC'tO[w Z . 7001
Time Cremation Started (p: KjM
Time Cremation Completed
'. Type of Container
Remarks ;
MA20 1 o . ss AM ova �r 10 A�1
i►�si h
I
. 4
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office:(518)745-4476,Crematorium: (518)745-4477
Audxxizadon 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: ,
ram. u �� .
(S�)
337L-L.� i�s-ynd PA k `kr
(Streo) (city) ) Code)
who died on day of 20_
at
(Place) ( )
Names and address of nearestg living relative or name of person audxxu nr,cremation: ,
rr " klC<`.Q�r3ac . pn &V. J
(Nome) (Address) 0J
Relationship to the deceased.
Name of Funeral Nome j2h P.c,,1 1�-
IMPORTANT:
I represent that to the best of my lohowiedge,the deceased(has)or ,aker,de WIlator,be",battery pack,power
colt,radioactive implant or radioactive device in his or her body.(Ci )
I certify that 1 have full power and authoriz&ion 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 Pere View C remalorium from any and all claim and demands for bes or damages which may be made against them
by reason of or connected with the cremation of sold remains as directed,whetter such del s or demands are or are not wholly
groundless,false or haudulert
(Witness)
(ems)
(Signature and Address of Relative or Legal Representative)
Signed on this dale: 1 - C� / "- M
Disposition of Cremated Remains
I hereby direct Pine View Ownstorlum to dispose of the cremated remains as follows:
Mail to
Other arrangements-Pleese specify. 1 u Atc d O _ c41 e n 0 �' �l-1 -m
If pulverization of cremated remains Is requested,check here x
Revision:April 18,2007