Smith, John 701+N OF QUEENSBUP*,.Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY. NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Directoriv /" /- /�/�-� �►'/ �/
Name ///� �/� i / �/7 Case # Q
Date of Crematicn ��� /
Time Cremation Started
Time Cremation Completed/ � / C
Type of Container k)eC'D (f/TJft-k / /S
Remarks :
17
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TOWb OF QUEENSBURY
PI VIEW CEMETERY
R 6
i--RrJAATORIUM
Quaker Road, Q6eensbury, New York l::804
Phone (518) Crematorium 745-4477 or if" no answer
Cenotery 745-4475
AUTHORILZATIO14 TO CREMATE
This undersigned :requests and authorizes Pine View Crematorium, .in
accordance wi Gh and subject to its Rules and Rs,gulationn to
criLm a the re ins of: _
(S,
(Name)
(C' y) (State) (Zip Coda)
who died on day of C/ lff 19-LL
at
G �
(Place) (Aicidress)
i
Naae and address of nearest living relative or , name of person
author' ! ins cremation:
7- h4VIO
(Name) 0ddress
l
Relationship to the
Name of Funeral Home a
IMPORTANT
I :represent that to the best of my knowledge, the deceased lion or
tiasa no pacemaker in his or her body. (Circle One)
I certify that I have the #ull 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 deattroyed, 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 thorn by
reason of or connected with the cremation of said remains as
directed, whether such -cli''ims or demands are or are not. wholly
groundless , false or fraudulent. _
SnT:itness) A ess) l4f2
_ s0v 1f
(Sign furs of Relative Le 1 p. and Add etas --
Si.rned on this date: O ,