Fake, Richard rroq+N OF QUEEN.5BU�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
a,:e�OQI'm — kel- Casey � !
Date Of Cremation -- � S -�Q �
Time Cremation Started
Time Cremation Completed 7 7 P
-T° 121 1
T�'pe of Container CP.S .9 arjo77 if-
Remarks
TOWN OF QUEENSBU13Y
PINE VIEW CEMETERY
CREMATORIUM
3 Quaker Road. Queensbury, New York 12804
Phone (518) Crematorium 745-4477 (if no answer)
Cemetery 745-4476
AUTHORIZATION -10 C13EMAI-E
The undersigned requests and authorizes Pine View Giematunum. in accordance with and subject
to it Rules and Re ulations to cremate the remains of.
(NAME) (SEX)
O'�a—, p AU-40�-V-... e,
(STREET) (CITY) (STATE) (zip DE)
who died on ja day of 20�
at—0- A k " , �6
P l
( LACE) (ADDRESS)
Name and address of nearest living relative �or name f person a(uthorizin rem on:
Relationship to deceased
Name of Funeral Home
IMPORTANT
I represent that to the best of my knowledge, the deceased has or ias n 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 m any and all claims and demands for loss or damages which may be made
agains the y r so of or connected with the cremation of said remains as directed, whether
suc a' s or are or are not wholl"oundless, false or fr ulent.
46 7 aY
WITNESS (ADDRESS)
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: l 2,Z e-,63