Mather, Gordon rO%N OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director'46 )4 /"'N I's
Name c/�RPCN Case # 13.6
Date of Cremation
Time Cremation Started !J 19 /9 rM.
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Time Cremation Completed 1/�,s-d 4 , " 1
Type of Container /g��, ��( � a/�j], C�S��F Tjy/c 01yy
Remarks :
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TOWN OF QUEENSBURY 13
PINE VIEW CEMETERY
CREMATORIUM
Quaker 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
eejremains of:
(Name) /� (Sex)
l 1c eewe
(S reet) (City) (State) ( Zip Code)
day of /���it1[�fyl�t�� �dC�
who died on � /Y/
(Place) (A dresA )
Name and address of nearest living relative or name of person
authorizing cremation:
(Name) (A res )
Relationship to the deceased
Name of Funeral Home ��/ �%�'� ✓ �
IMPORTANT:
I represent that to the best of my knowledge, 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 arranc
for the cremation of the remains and to direct the disposition
the cremated remains, that any personal possessions have eithf
been removed or may be destroyed, and agree to protect, defend an
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, false or fraudulent.
(-Wi-tl s s ) ' (Addr )
( ignature of Jte ative or Legal Rep. and Address)
6
Signed on this date: l .�