Buttling, Judith r'_0WN OF QUEENs5BU_�, Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, N-EW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director �Cr ' 4g4T-1IN�
Name I'a0l7V R() 772 1'46z Case # j p�
Date of Cremation
Time Cremation Started
1
Time Cremation Completed Z/ ,j A
Type of Container G,0�/7P,ye/}&_D
Remarks :
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TOWN OF QUEENSBURY Z30
PINE VIEW CEMETERY& CREMATORIUM
Quaker Road, Queensbury, New York, 12804
• (518) Crematorium 745-4477 of 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 Reguiatioris to Cremate the remains of:
i k J�U I L i'v G C/yiFirl L�
(Name) (Sex)
N'LY
(Street) (City) (State) (Zip)
who died on '�i N day of 140 yd tli G Ri 20_QJ_
at
(Place) (Address)
Name and address of nearest relative or name of person Authorizing cremation:
(Name) (Address)
Relationship to the deceased �t)Si3fn�
Name of Funeral Home
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or has no pacemaker 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 disposition of the cremated remains, that any personal possessions have either been 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 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)
(S' nature of Rel egal Rep. and Address))
Signed on this date: