Costanzo, Carol i
OF QUEEN
5BUr�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QU'EENSgURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name CARNL at-r y-i iv n-o Case# 2�
Date Of Cremation
Time Cremation Started
Time Cremation Completed 3 P
Type of Container � ,�4L � �✓-r�),�� ) ^
Remarks
IV--h
I
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone(518)Crematorium 745-4477(if no answer)
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes h�remains o Crematorium. in accordance with and subject
to its Rules and Regulations to
A &S,r�,t1 Y-tH4t 1=
(NAME) (SEX)
(STREET)
(CITY) (ST TE) (ZIP CODE)
who died on
day of 206 ,6
at ("U"
(PLACE) (ADDRESS)
Name and address of nearest diving relative or name of person authorizing cremation:
Relationship to deceased
Name of Funeral Home
IMPORTANT
I represent that to the best of my knowledge, the deceased has r has n acemaker in his or her
body. (CIRCLE ONE)
I certify that 1 have the 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 de rids or are not wholly groundless,false or fraudulent.
(WITNESS) {
ADDRESS)
(SIGNATU OF RELATIVE OR LFG L REP. AND ADDRESS)
Signed on this date: 61D, U