Archer, Jacqueleine " T-o RN OF QUEEN,5BUjr�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 4)/ 0'&h-;L
Name &—ca-A-fase # a l!
Date of Cremation
Time Cremation Started 1�Sd P—t t r
t
Time Cremation Completed
Type of ContainerG���� )r
Remarks :
APR-10-01 11 :33 AM R.W.WALKER FUNERAL HOME 51® 568 1749 P.02
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone ( 518 ) Crematorium 745-4477 or if no answer
Cemetery 745-4475
AUTHORI2ATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to cremate
the. rema,.r:s of :
(Streett} (CTty) l (Stst�e)(zip Code
who died on -- �� -� day of _ k9-2k- uI
-
(P ) VA ress )
Namu and address of nearest living relative or name of person
authorizing cremation :
�►-��. sue,h..►.r....��`���t�C.m c..ru��-.��✓t � ; �_�t�
(Name (Address )
Relationship to the deceased
Name of Funeral Home
IMPORTANT t •-` �^ 14VIC
I represent that to the best of my knowledGc, the deceased has or
has no pacemaker in his or her body. (Circle One)
I certify that 1 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 Dine. 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
gra idiec,L; , fa se or fraudulent .
� R
Z �.,DY �
(WI nesS) (Address )
(Signature of Relative or Legs] Rep. and Address )
Signed on this date : `� I __--.-__---
G I CC)� r1 S /