Loading...
LaCroix, Adelaide 70ltiN OF QUEENSBU9 y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director Name AG,p i%�-• Case# 2 -L Date Of Cremation Time Cremation Started Q s s M Time Cremation Completed --� 5� Type of Container (J14\Qp�,tZ� J © O � Remarks ��l2r�tci t--e) t N1aVrfse1 1 b 30 A-""\ 1 I I - I I I I TOWN OF OUEENSBURY PINE VIEW CEMETERY CREMATORIUM Quaker Road. Queensbury, New York 12804 Phone (518) Crematorium 745-4477 (if no answer) Cemetery 745-4476 AUTHORIZATION ]0 CREMAI-E The undersigned requests and authorizes fine View Uematonunr. in accordance with and subject to its Rules and Regulations to cremate the remains uf: Q de. 10-1 - kc Q r l (NAME) \ }� (SEX) 1 �1l 1 l ( 270 (STREET) (CITY) 1 _(-FATE) (ZIP CODE) who died on � day of 20 V�5 at 4-GI ICIS (PLACE) (ADD -SS) Name and address of nearest living relative or name of person authorizing cremation: Relationship to deceased c _1L j Name of Funeral Home 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 demands are or are not wholly groundless, false or fraudulent. (WITNESS) (ADDRESS) I— (SIGNATUR OF LATIVE OR LEGAL REP. AND ADDRESS) Signed on this date: I (7