Dutcher, Richard 70�vh� OF QUEEN,5BWZY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY. NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Direct or_&,E agy))
Name le'# P Case # jz
Date of Crematicn / ~
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Time Cremation Started
Time Cremation Completed
Type of Container G /,BSI,SEC)" 5 7i'ok �
Remarks :
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TOWN OF QUEENSBURY PINE VIEW CEMETERY 2� �
a
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 Pine View Crematorium,
accordance with and subject to' its Rules and Regulations to
cremate the remains of :
2 I c(.find) 0 �cWL,;2
(Name) __. _-. (Sex)
PJ t3ox u9 ( y1 6C�o2V 1-,q
(Street ) (City) (State) ( Zip Code )
who died on Z f day of
at G' l-� CSC rvS N
(Place) (Address)
Name and address of nearest living relative or name of perscn
authorizing cremation :
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Ph7R(CK G(. nu rc q c2 ,14,w 44 4.1 J7, L4*r G Ca2G ,xtt 12nrr
(Name ) (Address)
Relationship to the deceased 5'G7A)
Name of Funeral Home /4CZk/4^4V)C2
IMPORTANT:
I represent that to the best of my knowledge, the deceased -MF4=ao-=-
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 eitner
been removed or may be destroyed, and agree to protect , defenc
and save harmless Pine View Crematorium from any and all ciY�: mS
and demands for loss or damages which may be made against them ^ .
reason of or connected with the cremation of said remains as
directed, whether such claims or demands are or are not wnoi : ,
g nounss, false or fraudulent .
fitness ) (Address)
(Signature of Relative or Legal Rep. and Address)
Signed on this date :