Gifford, Thomas TO(KN OF QUEEVBU.Iky
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director +}
Name V&A eS cj't f:-Fo�z d Case#
Date Of Cremation l - 3 - c<
Time Cremation Started -V\1 '
Time Cremation Completed
Type of Container
Remarks
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TOWN OF QUEENSBURY ')
PINE VIEW CEMETERY& CREMATORIUM
Quaker Road, Queensbury, New York, 12804
Phone (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 Regulations to Cremate the remains of:
Y>? le
(Name) (Sex)
(Street) (City) (State) (zip)
who died on day of 5 r,n i3 jA 20 a
C
at
(Place) (Addr ss)
Name and address of/nearest relative or name of person Authorizing cremation:
ciilc 1 rcr� JrZ t.s.y1� S � � crr NY
(Name) (Address) 9
Relationph)p.to the deceased LAY,
Name of Funeral Home
IMPORTANT:
I=thatave
st of my knowledge, the deceased has or has no pacemaker in his or her body.
(Circle One)
I ull 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 crematio f said remains as directed, whether such claims or demands are or are not
wholly groundless, false or f ulent.
(Witnes ss)
r
(Signature of ative or Legal Rep. and Address))
Signed on this date: