Kattrein, Rita r� a
TOq+N OF QUEEVBU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Nameti `�"}� �; `�- �21 Case#
Date Of Cremation 4 ( - 2Go (?
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Time Cremation Started
Time Cremation Completed
Type of Containers A\'q'a '0() ) � 17 fl-�-
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
the remains of:
a � a 4
r (Nam) 1Z8
Inq
(skeet) (City) (Stare) (zip Code)
who died on day of 20—D(p
,y
at �A(� rn ada �'jC I �� n�v��i olil I
(Plem) (Address) -�
No"and address d nearest living relative or mitre of person authorizing aeration:
�enr�
Relatimahip to the deceased I U o l 1
Name of Funeral Home jAjk=4_.
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Ir�epreRseertthat to the best d my knowledge,the deceased(has) (has no) aoanreker,dafibril ator or any other battery operated
device in his or her body. (Circle One)
I certify that I have full power and aulhor¢ation to arrange for the cremation of the remains and to direct the disposition at the
cremated remains,that any personal posoesslons have either been removed or may be destroyed.and agree to protect.defend and
save horn less Pine View Crerrretorium>tom any and all do;:and demands for kiss or damages which mey be made against them
by reason of or connected kh t rat he aeion of said remains as directed,whether such claims or demands are or are n wh riot olly
lent
PDc
(ems) —
Address Relative or Legal Representative) 7
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Signed on this date: . 1 ►a t�D
Disposition of Cremated Remains
1 hereby direct Mine View Crematoriwn to dispose of the cremated remains as follows:
«,>aar,angemer,ts-Pteasespa�fy: r e lease -I-o -�u�i'1Q.r�c I hC�rl'�. re�Jres�+'��i+t v�-
if pulverization of aernated remains is requested,check here__
Revision:January 1,2006
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