Whiting, Diane • uY.kaaLcG _.........
7/--174 OF QUEENs5BU��� _y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director C /7/ // 7e— z
Name 2)'191Vo&7 (� )' t It/Y Case it
Date of Cremation /
Time Cremation Started f i
Time Cremation Completed ,-?",'��
Type of Container C �O� _
Remarks :
A1141,1*4 a0yvwRW
f �
f �9 m
�t 33 �M
_i9 f Io '
PAGE 4
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
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 fine View Crematorium, in accordance with
and subject to its Rules and Regulations to cremate the remains of:
—Dim Marie whi t�^n den I e
(Name) (Sex)
66 John. st a�cm Falls, NY 3 a23Q
(Street) (City) (State) (Zip Code)
who died on day of December 1992
at
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
(Name) (Address)
Relationship to the deceased Sister
Name of Funeral Home Gaa--Ieten Faneral u....e Lnde
IMPORTANT:
represent that to the best of my knowledge, the deceased has 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 destroyed, 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,
wheth such claims or demands are not wholly groundless, false or fraudulent.
68 Main Rt — Hi id'ran Falls , NY 12839
(Witness) n (Address)
FL
(S i gg A a-tur'eoffi4elative or Legal Rep. and Address) 33707
Signed on this date: ��-