Merchant, Robert TOUN OF QUEEVBU9 Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director " F601,,
Name Case# s \
Date Of Cremation 1 - 3 t _ 2- ®(! 3
Time Cremation Started ,a, 0 I1-41L
Time Cremation Completed /1/k, ••nn
Type of Container CA`c)`00w,-V__L) coo,\"\.
Remarks
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-JAN-28-03 TUE 12 :03 PM ETERNITY 714-771+5530 P. 02
JAN--27-03 MON 62:26 PM ETERNITY 714r771+Z330 P. 07
91/27/2683 15:82 518-797-1?87 REGAMDENf+/ #134E PAGe e'.
l TOWN OF QUEEN8SUMV
f PINE VIEW GEMi=TERY&CREMATORIUM
Quaker Road,Queensbury,Now Yark,12604
Phone(518)Crematorium 745 4471 of no answer Cometery 745.4476
1
AUTHORIZATION TO CREMATE
TNuntlerslgneo requests and authortres Pine View crematorium,to Accordance with and sub,eci to Its
Rull-is an R utat)ons to Crern the:tW rns vf.
(Name) x)
(street) i ) EMS) t _.,,._..� _..
Wht died on _ day of_ 20 f
r (Place) ( dreaa)
Name and address of re tide orYtafne of person Authoft ing c mmellon:
(Name) ( dreas)
Rel. tha deceased
Non O Of FWnera;Hartha
IMPORTANT.
I r present that to the best of my kmWedg+e,the deCedslld teas or has no Esker in his or tier Cody,
(Circle One)
I'm tify that I have the full power and suthorizatron to arrange For the crwa:ion of the remains and to
dira t the disposition of the cremated rem eft,that any pernonei passesel4 A Aa re eltfrar been mmoved
or rt ay be destroyed, and agree to prated,defend and save hanniess Plne Vlow Cremetorlum from any
and all claims and +Demands for toss or darnagm which may be made against them by reason of or
connected with the cremation of se mains as cfheated,whether su)h cairns or demands are or erne not
whu ly groundless,take ar iraExl eR
AUG,i
11-711)
(dvttness) / ea / �
(Sig of Reia've or Legal gap.and Address))
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md on thts Date:.
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