Vasey, Vivian i
T0%N OF QUEEVBU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEErNSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director F'Cr a k-NNL
NameV1 � J AH Case#
Date Of Cremation
Time Cremation Started t-( S
Time Cremation Completed
Type of ContainerC,p,%cy. j (:7j`6t+j c,a\e.Kr t- f NT 5"(� Y-)�
Remarks
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02/2e/2M 16:43 518-792-1297 REGAN&DENW #1346 PAGE r74
PINE VI CEMETEIRy&SCR
W MA74RIUM
Quaker Road, Oueensbury,New Yak, 12e0d
Phone{510)Crematorium 740-4477 of no answer Cemetery 7484470
. AUTHORIZATION To CREMATE
T undersigned requests and suttt Ines pine View Crematorium, in Accomance with and subject to its
Ru VS and Requistrons to Cremate the remains of:
C^
(N ) (sex)
h�
(3truat City) (State) (TJp)
w dled on L \ -- day of `"r'� _ 20
(Flec:e) tAOdreair)
N!r ia and address of nearest relative or norm of person AuthorIWg orome ion'
�• 1C.
ame) (Address)
RN tkrn;typ.to the deceased
Nw io of Funeral Noma f
IMPORTANr
r4 present that to the boat of my knowlodpo,fire d0coveed has or has no pacemaker in his or her body.
0016 one)
I (x Vy trtat I have the full power and audwrintlon b throngs For the cremation of to remains and lo
di ft d w"ition of the cremated remains,that any personal pooes$$Ww have either been mmwW
or
sy be destroyed,and spree to protect, defend and save harmless Pine View Crematorium from any
and all damns and demands for loss or damages which may be made atpainst them by reason of or
d with the cremation of said remains as dlrscted,whether such claims or demands are or are not
y groundless, false or frouduient.
n lonj {Address)
( net e o Re4ttive or at Rep. and rasa)
Signed on this dole. ._