Pahel, Jean OF QUEENSB21
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
i Funeral Director J3 A- �-� I Z'
a^,e 4040 / /7 :& Case# r2,,—) �1
`ate Of Cremation q G
_—.e Cremation Started 76
Ti-e Cremation Completed -A/U
. �. pe of Container
remarks
I
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 urdersigned requests and a 9mriaes Pine view CremhaEorlum,in aocordanee with and a Add to its Rules and Regulations to
cremate the remains of-
Q _
(game) (sex)
I "7 Cog` /el- Z �
( ) (gay) (state) (Mp Code)
who died on dayof V"j 20
at
(Place) ( )
Name and address of nearest relative or name of person autlodaing crametion:
i y'it t^,.� l 4'fl15 a u d;
(Name) (Address) s �Td P/ U
RelalioneW to the deceased S 0.•� _
Name of Final Home L1
IMPORTANT: Ute (has) no ,delib lMor or any ada battery operated
I represent ithsl�the best of ny bhohwladge. deceased (tree )
device In his or her body. (Circle One)
I certify that I halve ful pourer and artiori wdon to arrarge for the cremation of the remains and to direct tie disposition of the
aernated remains,that arry pare"possessions have eaher been removed or may be destroyed,and agree to protect,defend and
save harmless Pine view Chen corium him any and all ttaims and demands for loss or damages which may be made against them
byfeesondor V lthe c ematiorh of add remolns as drertecl.whether aurh dims ordemands we or are not wholly
(Sowhire and Address of ReletiMe or legal RePheserhtati+re)
Signed on this date:
i
Disposition of Cremated Remains
I hereby direct Pine view Cram etorhnrn to dispose of the cremated remains as MOM
Other arrangements-Please specify:
If PAVOrization of aemated remains is requested.check Mere
Revislon:January 1,2W6