Backus, Nellie rrO7tiN OF QUEEN5BUj(�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
( Funeral Director
Name /�l 1)�ase-1 2
Date Of Cremation_ 00
Time Cremation Started_
Time Cremation Completed 1 i
Type of Container' IAL � ,.`�
Remarks
^/ �L A�
l
TOWN Of- QUEENSBURY
• PINE VIEW CEMETERY
&
CREMATORIUM
Quaker Road. Queensbury• New York 12804
Phone (518) Crematorium 745-4477 (if no answer)
CeiYietery 745-4476
AUTHORIZA-I'ION 'I-O CREMAI-E
The undersigned requests and authorizes Pine View Ciematunum. in accordance with and subject
to its Rull�e/s and Regulations to
cremate the remains of.
(NAME) (SEX)
7 y 114,w 712-
(STRE ) (CITY) (STATE) (ZIP CODE)
who died on /5Jday of 20P_
la-
at 4-
(PLACE) ( DRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Relationship to deceased
1 d
Name of Funeral Hom -
IMPORTANT
I represent that to the best of my knowledge, the deceased has v tas no acernaker 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
suc I •ms or demands re or are not wholly groundless, false or fraudulent.
(WIT S ) (ADDRESS)
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: by �lC�`O