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Buttles, Catherine 70� � OF QUEEVBU9�y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director 11 TA)S �� Name lf�� Case# f Date Of Cremation Time Cremation Started 3 © � Time Cremation Completed 0 �� v Type of Container 41 04 Remarks s �� TOWN OF QUEENSBURY PINE VIEW CEMETERY CREMATORIUM Quaker Road, Queensoury, New York 12804 Phone (518) Crematorium 745-4477 (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: U �n o �,✓� e L� 4-G n I l (NAME) 4 L (SEX) / (STREET) (CITY) (STATE) (ZIP CODE) who died on day of Z4 20 0 at eS fY (PLACE) (ADDRESS) Name and address of nearest living relative or name of person authorizing cremation: .4, arA 14S" a mti it Relationship to deceased Ck' I �� Name of Funeral Home IMPORTANT I represent that to the best of my knowledge, the deceased has or has no pacemaker ' 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 qr d Rands or are not wholly groundless, false or fraudulent. (WI S) (AD ESS) / 4-- e) (SIGNATURE OF RELATIVE Oq LEGAL REP. AND ADDRESS) Signed on this date: �" O�