McShane, Sarah rrn`WN OF QUEEN,5BURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
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Funeral Director 1 A/s=
Name 5&g n Mif " Case #
Date or Cremation Z`— eq- - az?Qz
Time Cremation Started / '� ,'1.'3_j /41fm 1
Time Cremation Completed �/' o 'j
Type of ContainerK? (>49ohl?j] �' �1�� /11&F-0 f
Remarks .
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• TOM CAP QUEENSBURY
PINE Vt W CEMETERY
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CREMATORIUM N01—
Quaker Ftaat'!.Querenabury, Now York 12804
Phone (016) CrsmsWum 7454477 (if no answer)
Cemetery 745--4476
AUTHORIZATION YO CRENATE
The undersigned request`s and autho4as Pine View Crematorium, in acoordsncewith and sabject
to Its Rules and Reggulationa to Cremate the remains of:
(NAME) (SEX)
(STREET) (CITY) (STATE) (:.JP C�C1CI
Who died on �i �s✓ daly of 4e-
(PLACE) (ADDRESS)
.N vi address of nearest living relative or name of pemn authorizing crenvW!1-
Relationship to doosaead -
rrr•.. - r■ �ww w. w
Netrne of Funeral Homo '�o- 4-
IMP01VANY
I represent that to the best of my knowledge, the dacsased U1 o eceer to his or hor
body. (CIRCLE ONE)
I car* that I have the full paver and authorrotion to arrangs for the cremotion of the remains and
to dlrW ttu disposition of the cremated remains, that ony personal possessiotu rove either been
rsrnovod or may be de a!myod, and agree to "toct, defend and save harmless Pine View
Crematorium tom any and all cis)rns and demands br toss or damages which rr+ay De msdo
against Ih6m by reason of or connected vAth the orermVon of said remains as dtro-*d,whottr
su CIS] u ar demands are or are not wholly grourti im, tart"or fraudulent.
(1MTNESS) (ADDRESS) /
(SIGNATUREOF RELATIVE OR LEGAL Rom, AND AD RI?SS)
Signed on this date: