Jarosz, Anne 70'KN OF QUEEN
,5BU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
F u n e r a l D i r e c t o r
Name �� Case # �p
Date of Cremation
Time Cremation Started � / / °
Time Cremation Completed / l® ZLON
Type of Container
Remarks :
/414/N
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i
TOWN OF QUEENSBURY
PINE VIEW CEMETERY ,Q
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, in
accordance with and subject to its Rules and Regulations to cremate
the remains of:
A N m E AR05 L �E YM AL E
(Name) (Sex)
S CoupmwksE ae.. L.ALE rF0U6F , IDLY,
(Street) (City) (State) (Zip Code)
RA
who died on �, a3 day of 5T pFTrM 6E P. 19 17q
at LEnSS _4LL5 hup rrAl 6LCAI S fALL.S AJ,Y. l ob R
(Place) �� (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
(Name) (Address)
Relationship to the deceased Sin!
Name of Funeral Home ALFXh1F_R 'Futi EQ AL_ Romp—
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or
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 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
cted, whether such claims or demands are or are not wholly
gro n less, false or fraudulent.
- rt�t. 5, �I,EMIIEQ 3sol (''l��iiJ St-
(Wit ) (Address )
17
S1 n e of Rel ive or gal Rep. and Address )
Si ned on this e: 01