King, Floyd L
' rOWN OF QUEEN. B V� y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director �3 �l �
Name 1�,�`y� Case #
Date of Cremation - 2-4)G `Z
Time Cremation Started '`J [� )9 �.
Time Cremation Completed �f '" �� 14 A-I, ,
Type of Container6A\2o '\30 w?0 eJ Z.{A 1 O Ac F—
Remarks :
�1
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury. New York 12804
Phone (518) Crematorium 745-4477 (if no answer)
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in accordance with ano subject
,o its Rules and Regulations to cremate the remains of:
.I
-i6 P'e "y - z
AME) (SEX)
v
(STREET; (CITY) (STATE) (ZIP CODE)
f;: Qd ,
no Died on ✓'� day of 20
� ).t%1
C,J
at
(PLACE) (AD ESS)
Name nd address of nearest living relative or name of person authorizing cremation:
Relationship to deceased
—J6&- -1
Name of Funeral Home BR ER FUNERAL HOME, INC.
IMPORTANT
I represent that tc the best of my knowledge, the deceased has r has no pacemaker his or ner
body (CIRCLE UNE)
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
suc laims or d m nds or, re not w Ily groundle s, false or fraudulent.
(WITN ) f (ADDRESS)
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: V