Burns, Barry (-roj+N OF QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director +i�,Y�pf
Name rj,,t�, !�j-,r Case#
Date Of Cremation
Time Cremation Started
Time Cremation Completed I' uL
Type of Container -fc( �;,.� -J (Ir _r r C s
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:
:BARR L,' B U R N-S M R I e
(Name) (Sax)
(Street) (City) M (State) (Zip Code)
who died on .��� day of l Ip E 20-04
at SAIZ-roo i1% NuM� Sr SAQ67- A2i1,ii-S(Piece) J —� ((Address) - 4
r
New and address of nearest oft relative or name of person autnori&q cremation:
Mgc Ma IVA I' A-rmAN VA 11ey I&Aydm L Aj Ill V
(Name) (Address)
Relationship to the deceased Mci,rmca + --
Name of Funeral Worse�'In.fa. r�n e1Y crn KaAie A►a i �'O M r-
IMPORTANT:
I represent that w the best of my Imowladga,the deceased(tres) (has no) cerrhaleer,dolor or any other belts y operated
device in his or her body. (Ckde One)
I certify that I have full power and authorb aticn to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,that any personal possessions have eitiher been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View Creematorlm from any and all claims and demands for loss or rip i ges which maybe made against them
by reason of or connected with the cremation of said remains as directed,whether such dense or demands are or one not wholly
groundless,Was or /lent.
(Witness) ( )
k-woftue and Address of Relative or Legal Representative)
Slgrned on this dale: new d 3T 1b
Disposition of Cremated Remains
1 hereby direct Pine View Crematorium to dispose of the cremated remains as follows.
Map to
Other arrangements-Please specify: j
if pulverization of cremated remains is requested,check here
Revision:January 1,2006
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