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Constantine, Joan rl-n q+N OF QUEENSBURY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, :NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director 94 11 L R Name 121fN GOtV ,<ft6A L ?y Case # 3 2, Date of Cremation —7- Time Cremation Started l �, 7�? 0 Time Cremation Completed c a-7� Type of Containers fi471 Remarks : I �T C) P� TOWN OF QUEENSSURY PINE VIEW CEMETERY h CREMATORIUM Quaker Road, Queensbury, New York 12804 Phone (518) Crematorium 745-4477 or if no answer Cemetery 745-4476 AUTHORISATION 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 : a o.4N M- (feA1R 4A1T1,Ne (Name) (Sex) /7/ Ridge Sr. 6 /eers1"A1ls' Na.v-I&V- Ic (Street) (City) r (State) (Zip Code) who died on day of CC-(0 6 e Y baO at ajerV t 1'a ��S }-{o�p i t f�l- �Ys r� 11�'� ��e'r 'rk" (Place) T (Address ) Name and address of nearest living relative or name of person authorizing cremation: �osePh �i�vtl�n/Ir�le - ao? 1 r dye Xf - Arms /r, Pf' ocfeI (Name) (Address) Relationship to the deceased -J ow Name of Funeral Home 1V1,**R►-d A BA Kc-Y /`k Ne r 0(MAP,,e IMPORTANT: L-represent that to the best of my knowledge, the deceased has or has no pacemaker in his or her body. (Circle One) qE��> 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 cremation of said remains as directed, whether such claims or demands are or are not wholly groundless, false or fraudulent. 18E l IY Y. (Witness) (Address) Si at re of e i egal Rep. and Address ) Signed on this date: ©c�. ,5 - oZyyo