Hall, Fern TOWN OF QUEENSBURY
Pine Virtu Cemetery and Crematorium
21 Qunker Road, Queensbury, NY. 12804.5902
(5 18) 74 5-44 76 (518) 745.4477
http://wNvNv.queensbury.net
Funeral Director: -Al f3 Pr
Name of Deceased: /.-4-7- NFL �--
Case Number: 5 !J�
Date of Cremation: l 2 C--� 2 ��
Retort:(it-�-(Q W �--Q —CJ
Time Cremation Started: 4 0 1?
Time Cremation Completed: 7"S 0
Type of Container: C'� � �)4�t�1�-�- /t/� 'v, 62. C
Remarks:
5 2 r'i 12-q
2 Cj
" Home of NatllrnI BenuIy ... A Good Ploce to Live "
TOWN OF QUEENSBURY 45-
PINE VIEW CEMETERY
CREMATORIUM
It
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
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:
' f
(Name) (Sex)
(Street) (City) (State) (Zip Code)
who died on ' a day of �� _ ��oZx)(o
at `1
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
(Name) (Address)�
Relationship to the deceased �011'1
Name of Funeral Home M111i QPJ u ra- -
IMPORTANT:
I represent that to the best of my knowledge, the deceased.4
or
has no pacemaker in his or her body. (Circle One)
I certify that I 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 destroyedr 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 demands are or are not wholly
groundless, false or fraudulent.
Lk"%_'Z . - Z d
A dr s s
fitness) ( )
(Signature of R five or Legal Rep. and Address)
Signed on this date: -0 `)�
Town dQueensbury
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 wowsigrred requests and auawizes Fine view Cmmaiwium,in aooadence wkh and subject m its Rules and Rewilatiars to
cremate the rgm*w of:
) C, e�-c_ F�zr,azc�--
-- ( (sue
( (CRY) (sWO) (ZIP ODde)
who died on day of ao
at
O O
Name and address of neereet Nvkrg relative Or rrarrre Of person atrtharbdrtg awstlon:
048m) pldrtress)
RelooraW to the deceased
Name of Furtwal Moms
IMPORTANT:
i represent that to the best of my knowledge.I*dscaased(has)or(has no)pecernalcer,delb fttor or any other battery operated
device in his or her body. (Goals One)
I oertily that I have fuN power end arArorlVOW to arrange fa the asmadw of the remains and to dtred the disposition of the
aemteted remmkv%that any personal possessions hoe eiMw been removed or may be destroyed and agree tD PPi9teat.defend and
save h nrrless Plrts View Cnmv*orkrtn from wy and aN olakns and deermrds for loss a dwaegee which may be mUNION' '-them
by reeswo of a c mnecled wNh qre asnolb of said remains as directed,whether such deina a dwrrerwb area are not v*v*
gmur dless,false or fraudulent.
(VVNrress) , O
Lev C - ,
(Sowkwe and Address of Retddve or eprewKasttve)
Signed on this data:
Disposillw of Crenuded Roneft
1 hereby dkad Plea View Cremwak"to dispose of the awned remains as toNows:
MON to
Other arrerVe erft-Please WOW.
if pulMerization of aemeted remak+s is requested,check here
Rvvftn:Jammy 1,2W6