Starbuck, James ""'RN of QUEEVBUP.,..y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director J�)F�,' iNrA,
Name -jqN ES Case#
Date Of Cremation a - l — 2Gr-
Time Cremation Started
Time Cremation Completed
Type of Container `)y\,Pt + N&-C,0 nl� q �-��CJ 1�I►��1�I ��. �
Remarks
i
i
i
i
4 TOWN OF 01JEENSWRY
I PINE VIEW CEMETERY& CREMATORIUM
( Quaker Road, Queensbury, New York, 12804
' Phone(51a) Crematorium 745-4477 of no answer Cemetery 745.4476
I' AUTHORI7-AATION TO CREMATE
'The undersigned requests and authorizes Pine View Crematorium, In Accordance with and subject to its
HL les and Regulations to Crernate the remains of;
1
(Sex)
' _'-�--'��Wit) �--�-'-`�.t•:�c____._-mac. r. ,��) »� �->1- __ _ .,..
i (City) (state) (Zip)
w o died
day of_ 2
(Mace) (Address)
mlde and address of nearest relative or name of person Authorizing cremation:
L
(Naffie) (Address)
H labon$tt)p.to the deceased.._
rr ie of Funeral Home.._..._-.. �i..s r�.. ....aa .._
J IMPORTANT:
I present that to the best of my knowledge, the deceased has o as no acemeker in his or her body.
(Circle one)
t rtify that I have the full power-and authoftatfon to arrange For the cremation of the remains end to
di ct the disspositiott of the cremated remains, that any personal possessions have either been removed
or many be destroyed, and agree to protect, defend and save harmless Pine View Crematorium from any
a all claims and demands for loss or damages which-may be made against them by reason of or
ce 'neCted with the Cremation of said remains as directed, whether sr�ch claims or demands are or are not
w oily groundless, false or udulent.
(Ad ress)
48t e o it or egal Rep. an Address))
Srgned on this
T 0 'd 69bZ 699 409 4]fla8"IS NN" AzitiW ov: T T nHl ZO-6 T-OAa