Boyce, Patricia OF QUEEVBU9ZY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director �� � r��J 22x�N Lr
Name �� � /It-- (.-;,2,c-) Case# - ?�
Date Of Cremation
Time Cremation Started
Time Cremation Completed -3
Type of Container2LLI ,V,-�A,041?
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: c� l
Pm-t r i c i * 0 c
(Name) (SOX)
(Street) (City) (State) (Zip Code)
who died on z day of YYI , 2o OL
(per) (Add ss)
Name and address of nearest Irving relative or name of person authorizing cremation:
�j
"7 ce r� l e,`L e ` -
(Name) /(Address)
Relationship to the deceased 1�1 s Esc r�
Name of Funeral Home -
IMPORTANT:
I represent that to the best of my krrowledge,the deceased(has)OIE31pacemaker,defibrillator 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 arty and all claims and demands for loss or damages which may be made against them
by reason of or connected with the 7,
stlon of said remains as directed,whether such claims or demands are or are not wholly
groundless,false or fraudu r
(Address)
(Signature and Address of Re ive or Legal Representative)
Signed on this date: 2%
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