Arberger, Jack OF QUEEVBU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name �C�t\ P.C����� 12, Case# ZO
Date Of Cremation '.L_ �
Time Cremation Started
Time Cremation Completed � � '1 ✓L-1
Type o f Con t a i n e r od*xq-� S 1�1,:►7���J(:. c'o
Remarks
i -d
1 �1Y P-17
f TOWN 01: OUL=ENSBURY 5 Cfl
PINE VIEW CEMETERY /
CREMATORIUM
Quaker Road. Oueensbury. New York 12804
Phone t518) Crematorium 745-4477 (if no answer)
Cemetery 745-4476
AUTHORIZATION "I-O C13EMAI-E
The undersigned requests and authorizes fine View Liemalumm. in accordance with and subject
Rules and Re ulations to cremate the remains ul.
(NAME) (SEX)
(STREET) (CITY) (S ATE) (ZIP CODE)
who died on �1 day of 20
at
(PLACE) (AD RESS)
Name and address of nearest living relative or name of person authorizing cremation:
Relationship to deceased �1
Name of Funeral Home ,%,- 4 \-'`'
IMPORTANT
I represent that to the best of my knowledge, the deceased has o has no� emaker 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.
(WITNESS) (ADDRESS)
)(—Z;(a�(SIGNATURE OF RELA E OR LEGAL REP. AND ADDRESS)
Signed on this date: 41 C)3