Monterosso, Joseph TOq+N 4F QUEEN,SBU Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ��1
Name /., /!7 "'!:5 Case # �
Date of Crematicn �
Time Cremation Started / 5�/°02O7-/// j
Time Cremation Completed
Type of Container ,n///7 � Jt � lr�/����//7 �
Remarks :
A1.41 N 130/r yR-'P oaf
999 11 :41 518-745-4474 T 0 OUEDISBUFY rf*_1t
TOW I OF Q UEENSHURY
PI VIEW CEMETERY
s
REMATORIUM
Quaker Road, teensburYp
New York 12804
Phone (518) ""rOMarium 745-4477 or if no answer
Cem► tery 745-441,b
AUTHORIZATION TO CREMATE
The underrsigried roquests and authorizes Pine View Crematorium, in
aacordance with and subjeht to its Rules and Regulations to
cremate the remains
0"Me) L)Z
L Y�.�2 (City).
X /(State Co
Go 0
( reet)
who died on
day of
at e ..
(Place) ( e$
Name and address of neare�t living relative oz.- name of person
authori.zing cremation:
rra
v - I_Z2_ii9 � (Ad_dre �
Relationship tO the d*cO&se+� �Name of of Funeral Dome
IMPORTANT: knowledge, the deceased has or
I represent that to they be alt of
has no pac,tmak�er in his or her body. (Circle One)
I certify that. I have the full power and authorization to arrange
for the cxemat c,r. of the remains and to directpossessions have
i tiOn Of
aither
the cremated remains, that any personal pdefend and
been removed nr may be destroyed, and agree toprotect all,
claims and
save harmless Pine View Crematorium from any and
demands for loss or damag h may
eanat on made
of saidnst remainsns as
reason of or connected wi�th he Gs
directed, whether such clalimsor demands are or are not whcally
gro n ess , false or fraudull ant
'Tey - 1A _'p
Witn�+ss) W (A ess)
(Si nature of.` Relative or egal Rep. a A dress
Signed on this date'�..�-- d