Keep, Constance �o OF QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ",:) /*,,,A I-:�)
Name CO N`TA N CF= Case# Z 1 �Q
Date Of Cremation --,7
Time Cremation Started D ^/l
Time Cremation Completed
Type of Container (/•"tv-r"CZ. �3Ch4-\�-> o ; l
Remarks
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TOWN OF QUEENSBURY 2 C'
PINE VIEW CEMETERY
CREMATORIUM !
Quaker Road. Queensbury, New York 12804
Phone t518) Crematorium 745-4477 (if no answer)
Cemetery 745-4476
AUTHORIZATION -10 CREMAI E
The undersigned requests and authorizes fine View Gienralunum. in accordance with and subject
to its Rules and
Regulations to creniate the remains of:
(NAME) (SEX)
24A4
(STREET) 61 (CITY) (S-TAT -) (ZIP CODE)
who died on o?g day of ggj&� 2oD 3
atJ
(PL E) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
�, i 3 /
Relationship to deceased
Name of Funeral Home
IF
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 d ands are or are not wholly groundless, false or fraudulent.
L 7dl
NE PS) ADDRE S)
l'
(SIGNA E OF—RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date:
SUL LIVAN-NM
+ Z F"UNDIAL
Que�utb��Y tit �,
"Customer's Designation of Intentions"
Name of Deceased.: '�r •4! •.r �°_ ,l..s- ,,,/
Cremation:
(Scheduled Date) (Location)
Manner of Disposition of Cremated.Remains:
`
Burial at El'burial to Family
❑ Entombment at ❑ Other (specify):
I hereby designate the Disposition of Cremated.Remains and,acknowledge receipt of a copy of
this form.
(Signature)
(Printed Name) (Relationship to Deceased)
(Address)
(Telephone Number)
"Cremated. Remains which shall not have been claimed. within 120 days from the elate of
cremation may be disposed of by this firm by placement in a columbarium."
Printed Name of Funeral Director Syfature of Funeral Director Date
or Undertaker or Undertaker
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS
Cremation:
(Actual Date) (Location of Crematory)
Disposition of Cremated.Remains:
(Manner of Disposition)
(Location)
(Date)
Name of Person Making Disposition Signature Date
#9 WHITE:Funeral Home Copy. YELLOW:Family Copy PINK:Crematory Copy CU5INTEN Rev.4/96