Boerner, Otto rrOTAN OF QUEEVBU-WY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 22. 6�906--
Nameo7l:: a2E&9R Case # 0�
Date of Cremation '' 3 ' accnn
Time Cremation Started �� �� d/M
Time Cremation Completed let 3,z7,- / J / 1
Type of Containern, /�r(�
Remarks :
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TOWN OF ❑UEENSSURY r
PINE VIEW CEMETERY /l
CREMATORIUM
Quaker Road, Queensbury, New York 12604
Phone (516) Crematorium 74!5•-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 :
e> 0 �pe ! V�� /V i
d "IuIL
(Name) (Sex)
(Street ) (City) ( tate) (Zip Code )
who died on day of ✓" 1 c� I �oo�
at Re S ,tom,C Acc Co
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation : 1 /
(Name ) ( ddress)
Relationship to the deceased L-,) �
Name of Funeral HomeG�.S M�< <--
IMPORTANT:
I represent that to the best of my knowledge, he deceased teas or
hri' no pacemaker J•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 , d•s•!:nc'
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
grou dle a or 'Fraudulent.
fitness ) (Add ess >
�i60 VC-)
(Signature of Relat ve qr Legal Rep. annd. Address)
Signed on this date : 0. �X U