Berg, John rrOWN OF QUEENSBU-WY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD. QUEENSBURY. NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director A & 4 ,Tell a
N a m e 13,6-/l Case # c2s-
Date of Cremation 'b' oZ
Time Cremation Started A0 a
Time Cremation Completed >� c odc n M I
Type of Container r-hl?-Vlb19 j) aIVO,, Gi4-K,-
Remarks :
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JUH-12-2002 06733 DSC:A ADMIN 703 602 1671 P.03/07
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c tuaker R.Ad ouecrtobury,yew Yoi i., 12004
Pnon+�(51 8)Crwn0toriurr+74a-4477 of no answer Cemetery 74S-4476
AUTHCR171►YtON To CR"5MATE to It`
vi w Lr, matorium,ire ACcorrience with end subject
T4 undurAned requsets and autnoftes Ping e
Ru�3nd Regul�i� Grcmata the remains of
i (City)
(�trezt) {State) (Zip)
�y of
web Aked Uri
(Plat.) (AdCresG)
N�me and pddrpss or I learrat reidtave or tram,of person Authariairttra arerszat'on.
(Name) (Address)
R latiolls,ip to the docease0 IULC-
N me of Funeral dame
IMPORI'AN_:
knowl0dge,the ae ased)iss or naa no�camake<in his or net body.
I;reprosent that to thrr best of my (Circle One)
nd to
i e6fy that I have the full power•and authyation that to aporsoflna�o¢os �°n the orcm.ahsv®e Apr baennreamoved
d,ACt q1e dtyt�aaition of the orematod remain',,
rnut
v may be doeVVYl0,and agree to pr�� lne defend at•d save IWMIC»3 P view Crey re front f o
a d all r.talr!ts dcm3nag for 105.s or cremation of sold rerna�na asgCS e rncteci em
whether oucich may bp h ctaimSort�iehnands are of ro not
nnected w,th the
w ,olly gmndlaas,false or traudulent
� {Address).
(tM�tnrss)
i 1 ,
> (ftriatur'e of Relative or legal Roy.and Addrw))
Signed on this tiwte:.,! ' �"t"