Mead, Marguerite r
OF QUEEN,5BU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name—M AR&uF�j M FV�V Case#
Date Of Cremation C 20O 3
Time Cremation Started
Time Cremation Completed ( � v lot ' _ i
T vpe of Container 64A-v� ao'4ZJ M 1\'^ Iu Al1
Remarks 9.
-t
TOWN 01: QUEENSBURY
PINE VIEW CEMETERY 'Z 3 (�
CREMATORIUM
Quaker Road. Queensbury, New York 12804
Phone t516) Crematorium 745-4477 (if no answer(
Cemetery 745-4476
AUITIORIZA-TION -10 CREMATE
The undersigned requests and authorizes fine View Ciematomm. in accordance with and subject
to its Rules and Regulations to cremate the reniains of:
marqa-rlic'
(NAME (SEX)
a 0rl shtft- . 1 M�4
(ST EET) (CITY) (STA -) (ZIP CODE)
G' 63
who died on I D day of 20
at h Fi%k
(PLACE) (ADDRESS)
Nam and
address of nearest living relative or name of person authorizing cremation:
YQX
Relationship to deceased -�
Name of Funeral Home
IMPORTANT
I represent that to the best of my knowledge, the deceased has or e
acemaker 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 rernains as directed, whether
such claims or demands are or are not wholly groundless, false or fraudulent.
( NESS) (ADDRESS)
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
igned on this date: •S11 S 1