Ambra, Paul rro OF QUEENBUJ�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director i /44co"
M �-
Name MA b Case #
T
Date of Cremation
Time Cremation Started /` r"
Time Cremation Completed
T y p e c f C o n t a i n e r
Remarks :
A-
11/06/2001 09:25 5185854475 WILCOX REGAN PAGE 01
TOW OF GUEEN5OURY
DINE VIEW CEMETERY ` I
a
CREMATDRIUM
Quaker Road, aveensbury, New York 12804
phone (518) Crematorium 745-44776or if no answer
Cemetery
AUTHORIZATION TO CREMATE
in
The undersigned requessubaQctau�D°itgesRuIts Pint vand Regulationsiew to
accordance with and J
cremate the remains of
(Box)
(Name)
ID ga_�
(Street) tCity� (State) (Zip Code)
who died on day of
at
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:U-n a LLe F , � v
(N ) (Add ess) �l3�p
Relationship to the deceased `
,e rJL Vko m e-
Name of Funeral Home 1
IMPURTAN'Tz knowledge, the deceased has or
I represent that to the best of my (Circle One)
has no pacemaker in his or her body.
I certify that I have the full power and authorization to arrange
for the cremation of the rea�ains and to direct the disposition of
either
the cremated remains, that any personal Possetolorotectns � defend
been removed or may be destroyed, and ag p
clms
and save harmless Pine View Crematorium fainstany and allthemlby
and demands for loss or damages which may be m made ag
ed with the cremation of said remains as
reason of or connect
h Claims or demands are or are not wholly
directed, whether suc
groundless, false or fraudulent.
(W;nawc
t dre )
7�—
( of Rela ' ve or Legal Rep. and Address)
9igne ate