Hartung, Michael TOT�� o� QU.E L����SB `� y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name JC ���. A4g �6—_ Case # V02.
Date of Cremation J a&n/
Time Cremation Started
Time Cremation Completed `1gJr_/1 f Nq-
Type of Container/_' d9Djj2,d/9_0
Remarks :
/I / y4 �M �
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
&
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 (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 a d Regula ions to prem4te the remains of:
(NAME) (SEX)
C+-M lt2 9� 614tvj /4//i
(STREET) (CITY) (STATE) (ZIP CODE)
who died on / day of � 20 0 l
at G ''y� / 4m,� /
(PLACE) (ADDRESS)
Name and add ess of near t living relative or ppme of perso authorizing Z
ation:
e'
VW
Relationship to deceased �C
Name of Funeral Home
IMPORTANT
I represent that to the best of my knowledge, the deceased has k'tg=snoAlacemaker in his or her
body. (CIRCLE ONE)
1 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 agr6e 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 connectedZvith the cremation of said remains as directed, whether
such claims or demands ark of ark not wholly groundless, false or fraudulent.
(WITNESS) (ADDRESS�-
L / I A
h W
(SIGN RE OF RELATIVE O GAL REP. AND ADDRESS)
Signed on this ate: