Lake, Dorothy L
70%N OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director,j)',N�UF7,,PN
Name -kL-2otf) y lLh K E Case#
Date Of Cremation 2
Time Cremation Started 10 3 �J r"I -ql
Time Cremation Completed I �.� � ' " l
Type of Con tainerc-'4k'1�—OD 00 J;4 04, 1.0
Remarks l
CA -AIV
TOWN OF QUEENSBURY
• PINE VIEW CEMETERY
s �
CREMATORIUM
Quaker Road. Queensbury, New York 12804
Phone t518) Crematorium 745-4477 (if no answer)
Cemetery 745-44.76
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Ciematonum, in accordance with and subject
to its Rules and Regulations to cremate the remains of:
rZoTN ��� F
(NAME) (SEX)
f�K vy D/� s b u ry Iz got/
(STREET) (CITY) (S ATE) (ZIP CODE)
sr &kk lL- 2003
who died on � day of
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
L4&0aso6C2i "
Relationship to deceased
Name of Funeral Home j�/I��CT�1i� f ' -i Fkfu ly,
IMPORTANT _—_��
I represent that to the best of my knowledge, the deceased has or ha o pacemaker i 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
again t t by reason of or connected with the cremation of said remains as directed, whether
s I s or em ds are or are not wholly ground) ss, false or fraudulent.
401
( ITNESS) l (ADDRESS)
V •
(SIGN PTURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date:T t b >