Lanigan, John rl-o WN OF QUEEVBU9�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director-06ey$/Vb//?L
Name 1,61VIs ly Case # f
Date of Cremation '3 — 00a tq�
Time Cremation Started—; tM
Time Cremation Completed Ll
l
Type of Container
Remarks :
IzAne
TOWN OF QUEENSBURY
PINE VIEW CEMETERY 111
CREMATORIUM
Quaker Road, Queensbury, New York 12604
Phone (516) Crematorium 74g,-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 ;
--/V�� . l, L Cis✓�.i � c�, � '
(Name) (Sex)
(Street ) (City) ( tate ) (Zip Code )
who died on S `- day of ci r'-� 4%T -:t,CDv,.J
1 a t ,. —}
(Place) Address)
Name and address of nearest living relative or name of person
authorizing cremation : q } \ /
Lvn ( < - n' l D��_ �sY� R.v_'t Y+ Z.4 J FPt(-
ame ) ( ddress)
Relationship to the deceased—
Name of Funeral Home
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or
h s n acraak-yr-��i 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 Crematoriums 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, faj¢V or 'fraudulent.
itness > (Address )
(S ' gna ure of elative or Legal Rep. and- Address)
Signed on this da 4M 'kf" OdcJ