Donaldson, John rrO WN OF QUEEN,5BUJ�
PINE VIEW CEMETERY AND CREMATORIUNI
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name /� ��rj�/�/ Case # Q
c
Date of Cremation
f
Time Cremation Start /01 1nn
, r
Time Cremation Completed qQ 14"114 `
Type of Container g �// '"bh/D r#r. G/I -
Remarks :
Al' ,Ar-7
FROM M.B.KILNER FJNERAL HCNE FAX ND. Fe*).-' 03 2001 12:30PM P1
jpWN OF CUEENSBURI
PINE V:EW CEMETERY
CREMATORIUM
Quaker Road. Ouee^sou•y New fork 12804
Phone(518) Crematorium ;45-4477 ;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 and Regulations to cremate the remains of
o
(SEX)
(NAME)
AT
Q ;STREET) (CITY) (STAY (Z! CODE)
Za
who died on day of
at /PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
0
Relationship to deceased
Name of Fineral Home
IMPORTANT
I represent that to the best of my knowledge,the deceased hates has n pacemaker in his or her
body. (CIRCLE ONE)
I certify that�. have the full power a authorization ain that any Person I possessions have ion of the remains
been
to direct the disposition of the crew
removed or may ae destroyed,n a and daims Onee to protect.o a demands fore!loss a damages which ma'y be made
Crematorium from any
agai st hem b reason of 8r connectedor with essnf of aise or fre udulents directed,whether
suc aims o em n a
( NESS) (ADDRESS)
SIG ATURE O REj.ATIVE OR LnnEGA,,L R P. AND ADDRESS)
Signed on W dates �u