Cashdollar, Joan T01+N OF QUM
EB 2 1J y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENI SBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Directorl /Z/�i`n�� S
Name `y G� nalai9 Case
Date of Cremation
Time Cremation Started f
Time Cremation Completed
Type of ContainerA :�, �/ l"�� C_Cff
Remarks : �G�
3 v�
TOWN OF QUEENSBURY
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 remains of:
(Name) (Sex)
( Street) (City) (State) ( Zip Code)
who died on --��lp day of L"-/I/,,Y l
at C l/r'I-71 P/A G�<<iz 6-/� , i°fii l/
(Place) (Address )
Name and address of nearest living relative or name of per4on
authorizing cremation:
Y!�/Gj�d�t ri�i�.�a G ter/ LL/7r✓4/3��1��u1✓y ti•(� i Z`�,�L
(Name) (Address )
Relationship to the deceased
Name of Funeral Home 11-J /D"'l1'4V1X1 S' JSC)/tL5- .Z'uC ya?�
IMPORTANT: i c
I represent that to the best of my knowledge, the decej°dd. .r 4i3� or
has no pacemaker in his or her body. (Circle One)
► ' 1 try-,
I certify that I have the full power and authorization to arrapge
for the cremation of the remains and to direct the diposition, of
the cremated remains, that any personal possessions ,have either
been removed or may be destroyed, and agree to protect;,, def end, 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
groundless, false or fraudulent.
(Witness) (Address )
( Signat f Relative or Legal Rep. and Address )
Signed on this date: l Flo
S