Rathbun, Beatrice TOWN OF QUEENSBURY
Pine View Cemetery and Crematorium
21 Qunker Road, Queensbury, NY. 12804-5902
(518) 745.4476 (5 18) 745-4477
http://w\v�v.queensbury.net
Funeral Director: r�/,? �y
Name of Deceased:
Case Number:
Date of Cremation:— _ C
Retort:
Time Cremation Started:
Time Cremation Completed: .- �l
Type of Container: Co- �C)�C) cJ
Remarks:
17
1 :. 10
t L4 -3a P
t I n(3
" Howe of Nntitra1 8eaitty ... A Good P I n c e to Live " j
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
cxe to the remains of:
eA rt c,C F
(Name) (sex)600-0) ear /j Y a8
(Street) (City) j
A (State (Zip Code))
who died on day of �A/J&LA-2 20 o_/•
at A I SRayy treat 18AUy N y.
(Place) (Address)
Name and address of nearest rig relative or na of person aut rg cremation:
t i7'lf i 5� -!Cl 5 l28
(Name) (Address)
Relationship to the deceased 06J4 tt)
Name of Funeral Hom;yp��4A" �AtAA:o�
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,defibrillator or arty other battery operated
device in his or her body. (Circle One)
I certify that I have 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 Fine 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 arLdirected,whether such claims or demands are or are not wholly
grow ,false�udul �
Witness) ( )
(Signature and Address of Relatr4jor Legal Representative)
Signed on this date: 1,1/Z1
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
7Zc�
Other arrangements-Please specify* RAJ —^
E
If pulverization of cremated remains Is requested,check here
Revision:January 1,2006