Schermerhorn, Charline . TOWN Y Y N OF QUEEM,5BU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director /V/9y,�,�
Name CMA nl �j'C/y, /r/yf jP �/ Case # /OcZ
Date of Cremation
Time Cremation Started-4/1 e
Time Cremation Completed t eogz fm I
Type of ContainerTME
Remarks :
AA
I
I
i
i
i
I
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
& Jh
CREMATORIUM /�01Z
Quaker Road, Queensbury, New York 12804
Phone (518 ) Crematorium 745-4477 or 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)
i Z. ts'u:✓L ls�i'��' , �yo.s��J �iF' c 1, A/, i,
(Street) (City) ( State) (Zip Code)
who died on 6�e ,27 w day of f���"��'" ,2 a A
at /iye 11��1�'OiTi�L. �Ed��S F�'C t� 7✓�
(Place) (Address )
Name and address of nearest living relative or name of person
authorizing cremation:
1�'� cN c c� a ,� -t��/ , �/J L�'�=��..r✓E .�o, l,�vE Eve,Q✓,,� ,�! z.'d y
(Name) (Address)
Relationship to the deceased
Name of Funeral Home Z_ IVv�E
IMPORTANT:
I re resent that to the best of my knowledge, the deceased 1= or
as n pacemaker in his or her body. (Circle One)
I rtify that I have the full power and authorization to arrange
for he cremation of the remains and to direct the disposition of
the cr'ama,ted 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.
( itness) ( dress )—I)k Z , /
6Z-'-Z&Q
(Signature (Wef elative or Legal Rep. and Address )
Signed on this date: �J/e2.2- �