Feathers, Richard Sr. rrD`V N OF QUEEN,5BUi Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, INEW YORK 12804
(518) 745-4476 (518) 745-4477
4Funeral Director �/�(� �d/Z
Name6-- ddff—o j0j�//�jyFW "I Case # oz 9g
Date of Cremation Z `�` aocx-n
Time Cremation Started / ,' o6 h/M I
Time Cremation Completed 1/1 16�1 1Mp
Type of Container
Remarks : /
iAl2
Z--J�e h1 m
1� 3d z M
/n 133 A /A/)
TOWN OF QUEENSBURY n
PINE VIEW CEMETERY QV�cz
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 74!5,-4477 or if no answer
Cemetery 74-5-4476
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:
(Nam ) (Sex)
(Street ) (City) ( tate) (Zip Code)
who died on 2 day ofLf
at S� 1 0
(Place (Addres
Name and address of nearest living relative or name of person
authorizing cremation :
,old. A), r= a 1Z
(Na ) (Address) J
Relationship to the deceased
Name of Funeral Home
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or
c_T_W no pace make .i-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 demands are or are not wholly
groundless] falst Dr 'fraudulent.
Ca itness (Address)
(Signat ee of Relative or Legal Rep. and Address)
Signed on this dater -� �^� 9' . ��,�