Kearns, Barbara TOq+N OF QUEEN B219�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name Jl19R'81qz9 At Case # 'zo.
Date of Crematicn
Time Cremation Started
Time Cremation Completed 00
� C Type of Container -/T/iP/ 71 * - -OIV Z
Remarks :
r .
7
�� 11 let, X2 Z21 M
TOWN OF QUEENSBURY j,Q
pINE VIEW CEMETERY
A 4r
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 74$-4477 or if no answer
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
cremate the remains of: _
�1r t--11t4&- n '/Ga)�S" t
(Name) (Sex) y
51
(Street ) (City) (State) (Zip Code )
who died on day of L 19
at
(Place) ( ddress)
Name and address of nearest living relative or name of person
authorizing cremation :
I l IK' J /
(Name) (Address)
Relationship to the deceased
Name of Funeral Home
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or
ti no pacemaker J-n 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 creation of said remains as
m
directed, whether such claims or demands are or are not wholly
groundIess,''fa or 'fraudulent.
;;7Jhrr
(Witness) (Add res )
al�' a
ov
(Si Lure of Relative Zr Legal Rep. and Address)
Signed on this date : `T/