Dickinson, Sara o� �C OF QUEEVBUP,_y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director c (�
Name �C�,+-� L 1 i�k,✓l� h Case#
_ i spy
Date Of Cremation_
Time Cremation Started iQ;ds i4V�i
Time Cremation Completed .ate rYY
Type of Container CoAUow-1 M - "n ar) lU :/S
Remarks
-�—'L '� ISM Cc�Se a� c�l�,� !a ' �S ►4�
TOWN OF OUEENSBURY
` PINE VIEW CEMETERY
&
CREMATORIUM
Quaker Road. Queensbury, New York 12804
Phone t518) Crematorium 745-4477 (if no answer)
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Creinatonum. in accordance with and subject
to its Rules and Regullaat'ioonns�to�clremate the remains of:
A
(NAME) (SEX)
c"715 x—aQ IN1crti
(STREET (CITY) (STATE) (ZIP CODE)
who died on day of 20O_
atAr LC�1f�
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Relationship to deceased C a Lj 5 n
Name of Funeral Home L
IMPORTANT
I represent that to the best of my knowledge, the deceased has or a�nocemaker 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 c nected with the cremation of said remains as directed, whether
such claims or demands are o re not wholly groundless, false or fraudulent.
.g4 O/Q
( THE (ADDRESS)
(SIGNATU F RELATIVE OR LEGA EP. AND ADDRESS)
Signed on this date: Y
r _ 4
"Customer's Designation of Intentions"
Name of Deceased:
a
Cremation: y 1 �)) t �
(9rche4bled Date) (Location) It
Manner of Disposition of Cremains:
[-,A Burial at � c , � r i [ ] Return to(Specify person to receive cremains)
[ ] Entombment at
[ ] Other(specify):
I hereby designate the Disposition of Cremains and acknowledge receipt of a copy of this form.
(Signature)
(Printed Name) _ (Relationship to Deceased)
(Address)
51
(Telephone Number)
"Cremains which shall not have been claimed within 120 days from the date of cremation may be disposed of by this
firm,in the following manner of disposition
j7 ` La
Printe Name of Funeral Director Sign a of.Fun er irector ate
or Undertaker or Undertaker
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF REMAINS
Cremation:
(Actual Date) (Location of Crematory)
Disposition of Cremains:
(Manner of Disposition)
(Location)
(Date)
Name of Person Making Disposition Signature Date
I hereby acknowledge that on
Date
I took possession of the cremains of
(NAME OF DECEASED)
(SIGNATURE) (NAME OF PERSON RECEIVING CREMAINS)
White copy to family upon initial arrangement— Yellow copy to Funeral Home— Pink copy to family upon disposition
AP 27—REV 10/96