Guimond, John TO 7+N OF QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
�� Funeral Director S /0
Name�A � W &U i Case#
Date Of Cremation
Time Cremation Started /Y\
Time Cremation Completed
Type of Container-0 Y-11- �� '-0d da.kZr1
Remarks 1
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TOWN 01= OUEENSBURY
PINE VIEW CEMETERY
&
CREMATORIUM
Quaker Road. Queensbury. New York 12804
Phone t518) Crematorium 745-4477 (if no answer)
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Dine View Ciematonum. in accordance with and subject
to its Rules and Regulations to cremate the remains of:
(NAME) (SEX)
(STREET) 1 61 (CITY) (STATE) (ZIP CODE)
who died on day of ` 20Ql__
at6�-EZ—
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Relationship to deceased /,e_Z2
12
Name of Funeral Home �d���
IMPORTANT
I represent that to the best of my knowledge, the deceased has r has no 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 remains as directed, whether
such claims or deman are or are not wholly groundless, false or fraudulent.
(WI ESS) (ADDRE S)
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date:
407 sw Rod
J
QuseftAwy,MY 12804
"Customer's Designation of Intentions"
Name of Deceased.: ':- ! ;, ,• .
Cremation
(Scheduled Date) �t (Location)
M4iX*of Disposition of Cremated Remains:
Q"Burial at ".,,. r"r:.l z -nq- ❑ Return to Family
❑ Entombment at ❑ Other (specify):
I hereby designate the Disposition of Cremated.Remains and acknowledge receipt of a copy of
this form.
(Signature)
J ,!
(Printed Name) /,t r (Relationship to Deceased)
(Address) ✓�
(Telephone Numher)
t
"Cremated. Remains which shall not have been claimed, within 120 days from the date of
cremation may be disposed of by this firm by placement in a columbarium."
Printed Name of Funeral Director % Sig ture of Funeral Director Date
or Undertaker or Undertaker
. TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS
ACremation:
(Actual Date) (Location of Crematory)
w
' Disposition of Cremated Remains:
(Manner of Disposition)
1
L
(location)
(Date)
Nple of Person Malting Disposition Signature pate
##9 WHITE:Funeral Home Copy YELLOW:Family Copy PINK:Crematory Copy CUSINTEN Rev.4/96