Livingston, Wayne rrOTAN OF QUEEN,5BUi�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director/44C04)e—�kM
Name JLhi� �,�/i`, 7o� Case # Aw
Date of Cremation
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Time Cremation Started
Time Cremation Completed / 1 19 fMC
Type of Containerg�,9yaT,y
Remarks : iC�—
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8S/23/2000 0'' :10 518-71L-4474
ITOWN OF QUEENS13URY
PINE VIEW CEMETERY
8
fCREMATORIVM /Co
Quaker toad, Queensbury, New York 12804
Phone(5181 Crematorium 745-4477 (it no answer)
Cemetery T45-4476
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AUtHORII-ATION TO GREMAT C
i
The undersigned requests and authorizes Pine View Crematorium, in accordance will)And
subjec to its Rules and Regulation to cremate the remains of.
Zv '� f7L
( AME) gof SFX)
RAil. /7-6,C
(STPEET) (CI Y) (STATF) (ZIP CODE)
who died cn_ _ L _day Uf 1 200 --
(PLACE', (A ,bRESS)
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Name Lind address o`nearest living�elative or name of person euthorizIng cremation,
L4 44-D— Z -r70ea',,4j
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Relat!onship to decreased _1���� ___•--------__---- ---
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Name of Funeral HGMe ----
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IMPORTANT
I represent that to the best of my kn %)edge, the deceased has 0110
, n p iceniaker in his or her
body. (GIRDLE ONE) I
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I cer,iry that I have the furl power and authurizabon to arrange for the cremHUc�7 of the remains
and to direct the disr,•ositihn of the cr)ema.ted remains. that any Pe-11CMI Possess
lans have either
been removed or rT,7�be destroyed.Ignd agree to protect, defefTd ar)d sw#4 harmless Pine Vie`h
CrervBtOriUITT frcin any and all clalrn$and demands for loss or da.riages which may be made
agains!them I)y reason or or eor)ne ted will)the cremation of said rerrrains as directed.«helt;er
7jrSlft'.rTS�in _ 0tR Gf 7re d t`Af'.J+ty grGUndIeSS,faiSf!or flFTtllil!tP.nt.
(WITN SS) ACJURESS)
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(SIGNATURE ( REL.ATI`✓ OR U3AL RFP. AND AGORES '
Signed on this date.
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