Hala, Edward OF QUEEVBU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director �� � �, �Z
Name1�► Case#
Date Of Cremation
Time Cremation Started
Time Cremation Completed
Type of ContainerLo;��
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- 477
Authorization to Cremate
The undersigned requests and authorizes Pine View Crematorium,In acoadance with and subject to its Rules and Regulations to
cremate the remains of,
- � -
(Street) i _- (may) (sue) (zip code)
who died on day of Gl 20 ®O
(Place> (Address)
Name and address of nearest WN relative or name of person aWrofi&V cremation:
k-e 1 era +w� ---_ _ -
(Name) ice)
Relationship to the deceased
Name of Funeral Home !'
IMPORTANT:
I represent that to the best of my loxwAedge,the deosesed(has) ra errreker,datbrillaw or any other battery operated
daviop bn his or her body. (Cirde One)
I certify that I have full power and auttto W tion to arrange for the cremation of the remains and to direct the disposition of the
asmated remains,then any parsnnel possessions have either been removed or may be destroyed,and agree to protect,defend and
save to wgess Pine View Crematorium tram any and aft daims and demands for loss or damages which may be made against them
by reason of or cmr*x tad with the cremation d said remains as directed,wfwt her Such cieins or demands are or are not wholly
false or
(Address)
(Signature and Address of Relative or t egal Rerxrsar*91ve)
Signed on this date: --
Dfsposiioa of Cremated Remains
I hereby direct fine View m to dispose of the cremated remains as follows:
Other arrangements-Please specify.V-P le n'v -
If pulverization of cremated remains is requested,check here --
Reviskm:January 1,2006