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Young, Shirley r'-nJ+N OF QUEEVBU9 Y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 m Funeral Director t/\ DAl Name-:5H*'R a 00 4 G-- Case# 1 Date Of Cremation C)0 Time Cremation Started Time Cremation Completed 10 Type of Container Remarks mil- � ��,�� o� �►�� �� ' � 5 S �� i i i i i TOWN OF QUEENSBURY , PINE VIEW CEMETERY CREMATORIUM Quaker Road, Queensbury, New York 12804 Phone (518) Crematorium 745-4477 or if 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: S1 i L aUNG rC-1-1 � (Name (Sex) 2eA)t.0 G if S &3- (Street) (City) (Sta ) / (Zip Code) day of / /�� who died on Y ©Or at (Place) (Address) Name and address of nearest living relative or name of person authorizing cremation: _ &]A) (Name) (Address) Relationship to the deceased i S �n- Name of Funeral Home 1) . Row", fv ✓d M `- IMPORTANT: I represent that to the best of my knowledge, the deceased- has or has no pacemaker in his or her body. (Circle One) I 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 such claims or demands are or are not wholly groundless, false or fraudulent. ( itness) (Address) (Signature of Relative or Legal Rep. and Address) Signed on this date: �b0%3