Carswell, Charles Jr. T- OWN OF QUEEVBU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director �J /jiC.� 15alA
Name (i�I� �1�5 C ase #
Date of Cremat i cn '"/7 /
Time Cremation Started Ia t' Frm )
1
Time Cremation Completed 11! 30 / tM-N
Type of Container Q
Remarks :
A I N ,C3lJ/�it��R o.5! /02:o'Z49 /�'• JW)/
I1 �/ /• / ' Any
�i if 1s-C4. FM
TOWN Or OUEEN88URY
P I NE VIEW CEMETERY
A 77
CREMATORIUM
Guakwr Road, 3ueensbury, New York 12804
Phone ,718) Crematorium 741-4477 or if no answer
Cemetery 745-4476
AUTHORIZRTION TO CREMATE
Tne undersigned requests and authorizes pin! View Crematorium, in
accordance with and subject to its Rules and Regulations to
cremate the /remains ofi
(Name (Sax )
._._....._..
� iV 7T 71
(Street ) (City ) (state ) ( Zip Code )
)�+Cr
..hv c i rd on 60 day o f Zl_ 19 97
kplacr) (Address)
Nave and address of nearest living relative or name of person
autnorizing cremation : cam,
I_Zprv,2 C`Al�Scc)el/ /U � �e /�iLF�c �/2 �Dusf'S ;h'� l//• /o�97j
(Name ) (Address)
Felationship to the deceased
tiaMe of runeral Hone ,J'�50"'_ 1-4-47e-4/9C. iyyr e':
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or
nas no pacemamyr in his or her body. (Circle One)
1 certify that 1 have the f u 1 1 power and authorization to arrange
for- the cremation of the remains and to direct the disposltion of
the cremated •-emains, that any personal possessions have either
been removed or may br destroyed, and agree to protect , defend
and save harmirs5 PInu View Crematorium from any and all claims
ano demands for : oss or damages which may be made against thew by
reason of or connecteu with the cremation of said remains as
directea, "hetner such claims or demands are or are not wholly
groundless, false or fraudulent.
(WI tnoss ) , (Address )
s �
lg t re cf Rel tive or Legal Rep. and Address)
� ignrd on this date :