Law, Josephine E. Jowth o ueew ur�
PINE VIEW CEMETERY and CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12801
(518) 798-4726
(518) 793-9777
Funeral Dirictor
Name �� S /"/7/r/y /7 Case No
Date of Cremation G3
Time Cremation Started ,'�� /,I/
Time Cremation Completed S
r rr Type of Container C-,dXDZ0/9/f'P / S 7_/ �,+gS�C= c�/c T/0�`A2z!2'X
Remarks /��/�/C� ,�L��/1k X ei!l /y _ C� i�
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TOWN OF RUEENSBURY
PINE VIEW CEMETERY
ac
CREMATORIUM
Quaker Road, Rueensbury, New York 12804
Phone (518) Crematorium 798-4726 or if no answer Cemetery 793-9777
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:
J7
Name Sex
Street ity State Zip Code
who died on day of 19�
at tS _ .
Place Addres
Name and address of nearest living relative or name of person authorizing cremation:
P� 2
Y
0 G /(F ZdrlC)h
Name Ad ess '
Relationship to the deceased
Name of the funeral home
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 of, or connected with the cremation of said remains
as directed, whether such claims or demands are, or are not, wholly groundless, false or fraudulent.
`Wi nes
Signat of elative or Legal Rep.
Ad ess
Address /
Signed on this date_ - 5