Moffit,Ella rrO WN OF QUEEVBUr�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral DirectorZM970 `( — 114C - At
Name ��/4 /V, Z/ / Case #
Date of Cremation " of C27�/
Time Cremation Started 91" y
Time Cremation Completed //i'f/�
Type of Container ZFV6, ARD aX0 , Gz95o&- F— 7-W.oF--p�l/
Remarks : -2 L:- - ✓/
I HEREBY EXPRESS TO MY SURVIVORS MY EARNEST DESIRE AND REQUEST THAT ON MY DECEASE MY BODY SHALL
BE CREMATED AT PINE VIEW CREMATORIUM, ON QUAKER ROAD, TOWN OF QUEENSBURY, NEW YORK AND FURTHER DO HEREBY
ORDER, DIRECT AND AUTHORIZE SUCH CREMATION.
1
(Signed)
(Address)
Witness ply
Address 4 442
Dated_
TO BE ENTRUSTED TO THE SIGNER'S EXECUTOR OR NEXT OF KIN BARTON-WDERMOTT
FUNERAL HOME INC,
(Return copy to PINE VIEW CREMATORIUM, Quaker Road, Queensbury, N.Y. 12801) Pine Street
Chestert Wn, NY 12817
k
TOWN OF QUEENSBURY �(J
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 rem ins of:
(Name) (Sex)
(Street) (City) (State) (Zip Code)
who died on day of - ,-t �9�C�cJ
at
(Place)
(Address)
Name and address of nearest living relative or name of person
authorizing cremation:
(Name) (Address)
Relationship to the deceased v rax-d ",u
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 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 ndle ss or fraudulent.
( z-eds (Address)
(Signature of Relative or Legal Rep. and Addr s) h
Signed on this date: