Dishon, Charles rl-o q4N OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director / 67614
Name GZza 15 &N Case #
Date of Cremation, "p —'o
Time Cremation StartediCh
Time Cremation Completed
i
Type of Container ef
Remarks : G'`�/�k �/WD
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (516) Crematorium 74g,-4477 or if no answer
Cemetery 74'5-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes 'Pine View Crematorium, :n
accordance with and subject to its Rules and Regulations to
cremate the remains of :
(Name) o (Sex) —
Ko / � �oi.A, fit, /J 7' j -A
(Street ) // (City) ( ttaate) (Zip Code )
who died on lQ — day of oE)J
at a r c.,4
(Place) I(Address)
Name and address of nearest living relative or name of person
authorizing cremation :
L�et-r
(Name ) (Addres )
Relationship to the deceased L-1 t_
Name of Funeral Home
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or
hx no pacema er ',n 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 dem*ands are or are not wholly
groun s -f jrop 'fraudulent.
Avle
(Witness ) (Address )
(Signature of Relative Legal Rep. and Address)
Signed on this date : V"1 a OvJ