Bushey, Wayne OF QUEEVBU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 11 K, 1+Rut
Name �Ntiriz 3 hty Case#
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Date Of Cremation - 1�,� c; `
Time Cremation Started 1O
Time Cremation Completed I41 y �
Type of Container C',�r( �,��,, ;P � 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:
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(Nam (Sex)
at) f. - ei I��VA' p
(Street, (City) (State) , (Zip Code)
who died on 1 A day of� 20�
at
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(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
V�bqA !bi -Aieta �Ah�.J - fiv�
(Name) (Addres )
Relationship to the deceased LA�Li
Name of Funeral Home M. B. Kilmer Funeral Home
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has) (has no pacemaker,defibrillator or any other battery operated device in his or her
body.(Circle One)
1 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 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.
(Witness) (Address)
ignature an ddress of Relative or gal Representative)
Signed on this date:
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