Gebo, Milton rro WN of QUEEVBU-'�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name Case # eQ
Date of Cremation oL a
Time Cremation Started Z.r"�/ 11
Time Cremation Completed $ tl5`191m i
Type of Containerl'j� )�Y 777/ cd5fi5E-r-zt� • vim Ti�f ,a,E'�
Remarks :
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TOWN OF QUEENSSURY
PINE VIEW CEMETERY
&
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:
(Name) (Sex)
/e6 ,5TT� R• 22. Wt ;Th14<r N
( Street) (City) (State) (Zip Code) ,
who died on o? day of z 'e
at ",C,'675 1'At-c s ,�Snot Tc
(Place) (Ad(dress)
Name and address of nearest living relative or name- of ;i son
authorizing cremation:
47�.9 S7-&_rg )eT 2t!-
(Name) (Address )
Relationship to the deceased 1�A4Ghr7eP_ 41
Name of Funeral Home y"//y0'M
IMPORTANT:
I represent that to the best of my knowledge, the deceased
has no pacemaker in his or her body. (Circle. `One)
i certify that i have the full power and authoriz.at, on, tep Ax,, anW
for the cremation of the remains and to direct the, disposition of
the cremated remains, that any personal possessions.. have ether
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 )
( Signature of Relative or Legal Rep. and Address )
Signed on this date: