Nestie, Ralph OF QUEEVBU-r�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name 1' �-I 1y�-t1 17- Case; "Z
Date Of Cremation [ - 3 ZGG
Time Cremation Started_ d 9-1-1
Time Cremation Completed_ �� �>A-X
Type of Container Z�- c%� I f3O �? c) LA ki � 13S 2►
Remarks
TOWN OF OUEENSBURY
PINE VIEW CEMETERY 'r
CREMATORIUM
Quaker Road. Queensbury. New York 12804
Phone (518) Crematorium 745-4477 (if no answer)
Cemetery 745-4476
AUTHORIZATION TO O CREMATE
The undersigned requests and authorizes Pine View Lrenratunum. in accordance with and subject
to its Rules and Regulations to cremate the
ieemains of:
(NAM E) D (SEX)
(STREET) (CITY) (STATE) (ZIP CODE)
who died on o2 day of Q,�.,-+� 20�-'3
at v 4
(PLAC (ADDRESS)
Name and address ofL nearest
tlliving relative or name of person authorizing cremation:
Relationship to deceased
Name of Funeral Home
IMPORTANT
I represent that to the best of my knowledge, the deceased has has n pacernaker 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 con cted with the cremation of said remains as directed, whether
suc=�r s are or a not ly groundless, false or fraudulent.
I NESS) (ADDRESS) pn e
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: GT 0