Barton, William 70�v OF QUEEVBU,9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name [�Cj C r. Case#
Date Of Cremation �; � A,
Time Cremation Started_ v A
Time Cremation Completed fa° 1iJ hM
Type of Container1st �h5�
Remarks
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12804
Cemetery Office: (518) 745-4476, Crematorium: (518) 745-4477
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:
(Name) (Sex) /
�. h 5 err 1t � �r. S l r'� �
(Street r� (City) (State) (Zip Code)
who died on d �f day of 1 20104
at a e
(Place) (Address)
Name and address of nearest living ve Jor name of person authorizing cremation:
(Na roe) ( )
Relationship to the deceased
�y
Nae of Funeral Home �I/ < S n��
m r C- 7� 1�-
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or as no)pacemaker fibrillator or any other battery operated
device in his or her body. (Circle One)
I certify that I have 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 wt>ich 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
n iraudu
p (wit (Address)
(S ature and Address of Relative or Legal Representative)
Signed on this date: a O o
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
Revision:January 1,2006