Taylor, Helen i
L O Y YN OF QUEEVBWU
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director Jj u 'ss . IJG-
Name H r— s7 Case # ' y
Date of Cremation 9^ �
Time Cremation Started 9 � `
Time Cremation Completed / � ' ( S 14 ' 7?c(
Type of Container 1�} l2� �JQ ' cogs '�- cf4S<<-
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Remarks :
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TOWN OF QUEENSBURY �'5r L
PINE VIi-W GEMETERY '
Q
CREMATOPIUNI
Quaker Road, Queensbury, New York 12804
Phone t518i Crematorium 745-4477 (if no answer)
Cemetery 745-4476
AUTHORIZATION 'TO GREfvMATF
The undersigned requests and authorizes Pine View Crematorium, in accordance wim and subfe�_i
to it,,-, Rules and Regulations to cremate the femains of.
Z-d*—
f NAM E) tSEX)
Cj L /f eA�!T/� !/9 S /U,7 �4 Slplz s✓�S N -1 �Z ✓� --
STfZEEI''. (CITY) ;STATE) we--to— Ei
�ih^ led on / day of
at# -
"PLACE) (ADDRESS' /
Name and address of nearest living relative or name of person authorizing crernati�_)n
Relationship to deceased u� _.i ��_ .- -- -----------.-----_.----- ---
Flame or Funerai Horne,
IMPORTANT
I represent that to the best of my knowledge, the deceased his,o gas n pacennaker in nis or ner
ticcty (CIRCLE ONE)
I certify that I have the full power and authorization to arrange for the cremation of Ine ;emains ano
to direct the disposition of the cremated remains, that any personal possessions have either been
removed ,)r may be destroyed, and agree to protect, defend and save harmless Pine View
Crematorium from any and al! claims and demands for loss or damages whiuh may be made
against them by reason of or connected with the cremation of said remains as directed, whetner
c,jch Maims or demands are or are not who!ly groundless, false or fraudulent
!WITNESS)- tADDKESSr~ �J
7A, -l, ,,,L
fGNATURF OF R LA IVE OR LEG REP. AND ADDRESS)
,igned on this date_ /L-lS '`jy _ __
DISPOSITION OF CRZKATED PJMoAZN-Q
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POLICIES! RULES AND REGULATIONS
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