Timms, Sidney TOWN OF QUEENs5BUrky
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY. NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
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Name � ci �/e J I ( /� /!l S Case # y
Date of Cremation /C-)
Time Cremation Started ✓"-' � ��� )
Time Cremation Completed 16 P 191
Type of Container I.c/fJ 0 6 a4 1ST C8i :5e ea /Tl
Remarks : C. ' '
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TOWN OF OUEENSBURY
PINE VIEW CEMETERY
a
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-447*7 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:
(Name) (Sex)
�LAIG " �-c-� 06,
(Street ) (Cit (State) ( Zip Code )
who died on I�, day of \ 19 1
at G 2�' 461�p
(Place) (Address )
Name and address of nearest living relative or name of person
authorizing cremation :
(Na e) (Address) p
Relationship to the d ZCAC�
ased_
Z%-- -
Name of Funeral Home A-
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
directed, whether such claims or demands are or are not wholly
groundless, false or fraudulent .
(Witness) (Address )
\ � �vY✓j Zr��4
(Sign tune of Rejative or Lega+ll Rep. and Address)
Signed on this date : ��`
RE,,�-�%N1 & DENNY FUNIEW�i., Sk,k'.,,,V10E
53 Quaker Rowl
Qucensbury,New WA It 22.(P
18)79-2-11 1:1
"Customer's Designation of Intentions"
Name of Deceased
Cremation: J- -4 Ij 4�
(Scheduled Date) (Location)
Manner of Dis sition of Cremated Rquam' s:
XBurial at=�Cw — 0 Return to Family
0 Entombment at 0 Other (specify):
I hereby designate the Disposition of Cremated Remains and acknowledo receipt of a copy of
this form.
kill
(Signature)
(Printed N.1) (Relationship to D.;; )
V,
(Telephone Number)
"Cremated Remains which shall not have been claimed within 120 days from the date of
cremation may be disposed of by this firm by placement in a columbarium."
'j-
Pkintea Naipe of Funeral Director Signs aof Funeral Director Pate
or Undertaker r Undertaker
TO BE COMPLETED]FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS
Cremation:
(Actual Date) (Location of Crematory)
Disposition of Cremated Remains:
(Manner of Disposition)
(Location)
(Date)
Name of Person Malang Disposition Signature Date
#9 WHITE:Amerd Home Copy YELLOW Family copy PUM.Crematory Copy CUSH,-TMN Rev.4196