Pereau, Ralph rroqlN OF QUEEN,5BU-' �
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director A � �jL ��
Name �' ' vl / ! P� aCl� Case # �3
Date of Cremation a2
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Time Cremation Started
Time Cremation Completed
Type of Container
Remarks :
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Qt*ker 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: /
sOgv. (N me) (Sex)
V.e
(Street) (City) (State) (Zip Code)
-who: died on ` �j day of v T
at
t.
Place) (Address) /Lf�i7
Name and address of nearest living relative or name of person
authorizing cremation:
(Name) (Address)
Relationship to the deceased
Name of Funeral HomeZZ
IMPORTANT:
I represent that to the best of my ;1nowledge, the deceased has or
has no pacemaker in 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
gr undless, a s o fraudulent.
(Wit es ) (Address )
Sig rfatur'e of Relative or Legal Rep. and Address )
Signed on this date: