Wilsey, James TURN OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director�J
Name Case # C�
Date of Cremat i cn 'T ) VI
Time Cremation Started ,- /7 f� 1
Time Cremation Completed "
Type of Container —
Remarks :
/7 ,
11 //
- c
TOWN OF QUEENSBURY
l
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 Pine View Crematorium,
accordance with and subject to its Rules and Regulations to
cre�te the remains of :
J��QI,9s W ./S
(Name) ( e.x)
C JYer )eq�t r, �e
(Street ) �1 (City) (Stat ) ( Zip Code )
---
who died on �� day of �-6rC 19�
at ' /kS /� le
n �9//�
(Place) (Address )
Name and address of nearest living relative or name of pens
authorizing cremation :
u r e 11S
(Nam (Address)
Relationship to the deceased
Nave of Funeral Home
IMPORTANT:
I r sent that to t est of my knowledge, the deceased has or
as no pacemaker in his r 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 , deferc and save harmless Pine View Crematorium from any and all claims
and demands for loss or damages which may be made against them c ,
reason of or connected with the cremation of said remains as
directed, whether such claims or demands are or are not wni ,:
groundless, false or fraudulent . o
(Witness ) Q (Address)
(Signature of Relative or Legal Rep. and Address)
Signed on this date ?rL,