Webb, Sally T07+N OF QUEEVBU-'�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
,19
Funeral Director l"1 ZV t �1�
Name b)eiO Case # to
Date of Cremation �` ��
Time Cremation Started -7 J A^
Time Cremation Completed �, Q
Type of Container [' A Q 4!QA
Remarks:
1m//y 0601 ly,09W oaf
TOWN OF OUEENSBURY
PINE VIEW CEMETERY
a
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
cremate the remains of:
7G�
Name) (Sex)
_tic
(Street ) (City) (State) (Zip Code)
7 14 day of 19
who died on
at�U o� cif lCPPivt'
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
�J Ay.l� P. c,�Et37 /8 Rr�i�1s�711 �T, 8/�v�tGiyyl A y
(Name) (Address)
Relationship to the deceased
Name of Funeral Ho
Name
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 ri!mains as
directed, whether such claims or demands are or are neat wholly
groundless, false or fraudulent.
4
(Witness) (Address)
�L '0' kldw
(Signature of Relative qr Legal Rep. and Address)
!=; l.�vd on this date : ';�/