Armer, Matthew . rrnTtN OF QUEEM
,5BU9�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ,(�- 7<04 - /T� 7
Name /Vii9 � /g/Q11✓� /1 Case # -.5-4�0
Date of Cremation An —30 — ac39
Time Cremation Started xT r1m I
Time Cremation CGmoleted �� ;�(M}
Type of Container
Remarks : ��
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TOWN OF QUCENSBUAY
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 and Regulations to cremate the remains of:
(NAME) (SEX)
.� 6-1
(St EI:T) (CITY) ("STATE) (ZIP CODE)
who died on_ of day of 20,C24
at 4 lboll Icy l v n-
(PLACE) (ADDRESS)
t
Name and address of clearest living relative or name of person authorizing cremation:
r
_Relationship to deceased
Name of Funeral Home 7
�U
IMPORTANT
I represent that to the best of my knowledge, the deceased hu or pacema 4r in his or her
body. (CIRCLE ONE)
I certify that I have the full power and authorization to arrange for the cremation of the remains and
to direct the dispositlon of the cremated remains, that any personal possessions have either bRen
removed or may be destroyed, and agree to protect, defend and save harmless Pine View
Crematorium from any and all claims and demands for loss or damages which may be made t
against them by reason of or connected w h the cremation of sold remains as directed, hether
such claims or demand 7reor who groundless, false or fraudulent,
d Jar �
SS) AD SS} /V�
(SIGNIUR OP Rcu IVE 00 LEGAL REP AND ADDRESS)
Signed on this date:_
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