Soron, Edward Jr. �O WN OF QUEEVBUXY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director jAs jl/q6z a(,calvjyfl�
Name -�b�}yJ �jQ ► Case #
Date of Cremation % 7N— 6ktT6
Time Cremation Started '1/ 6Z4 P' m ►
n t EA4Time Cremation Completed � ' �Q'
Type of Container C'z���BO�IKD gN,71 G�,�c�IF7, T�,E-41
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Remarks : � )�7—
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TOWN OF QUEENSBLJRY
PINE VIFW CEMETERY
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Otiaker Road, Queensbury, New York 12804
Phone (51¢) Crematorium 745-4477 (if no answer)
Cemetery 745-4416
AUTHORIZATION I C CRlrli E
The undersigned requests and authorizes Pine View Crematorium, in accordance wiin and subje. i
to its Rules and Regulations to cremate the remains of.
(NA..ME (SEX)
STIZEFT :CITY.) ;STATE) (ZIP Co Ci
.Yh,r died on day ::f �!✓�c:� e!- ;�- GOC�
at—/.7_.� 1TE �'. -----
{F'i.A!'`<) ;ADDRESS)
Name and address of nearest living relative or name of person authorizing crerr;at+,in
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Relationship to deceased -VAC ---
game of Funerai Horne
IMPORTANT
I represent that to the best of my knowledge, the deceased b.�j or 1 s n 'ace'l Aker in nis a' nef
ONE_1
I certify that I have the full power and authorization to arrange for the cremation of me �emains an
to direct the disposition of the cremated remains that any personal possessions have either ,beer
removed or may be destroyed, and agree to protect, defend and save hart'niess Pine- View
Crematorium from any and al! claims and demands for loss or damages whlcl-i ma`I e made
against them by reason of or connected with the cremation of said remains as directed, whetner
s+jch Mairns or demands are or are not wholly groundless, false or fraudulent
- G-�er�L7E%GeZ C//Z
(WITNESS) �RESS) - ._�.------- ---------- -
744 je
). IONATUR.- OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date
DISPOSITION OF CRVIVATED PMM1NS
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POLICIES, RULES AND REGULATIONS
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