Town, James Sr. rOTvN OF QUEEVBUJ�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
ame �, LAI TOwN S& Case;- (�
ate Of Cremation — -Z
Time Cremation Started 11 44 M,
Time Cremation Completed
T`-pe of Containerowl 'bDs-,\XX `� `�4 /►�
Remarks
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TOWN Of QUL=ENSBURY r r�
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road. Queensbury, New York 12804
Phone t518) Crematorium 745-4477 (if no answer)
Cemetery 745-4476
AUTHORIZATION l 0 CREMAI E
The undersigned requests and aulhwizes Pine View Liematomm. in accordance with and subject
to its Rules and Regulations to cremate the iemains ul.
[
1 O W'(1
(NAME) (SEX)
G -ci-r r tS?i � 1 c�O\A
(STREET) (CITY) (STATE) (ZIP CODE)
who died on P;�"�) day of 20
at N-S)— lU4 it)C
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Relationship to deceased
Name of Funeral Homed
IMPORTANT
I represent that to the best of my knowledge, the deceased has o has n 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 demands are or are not wholly groundless, false or fraudulent.
(WITNESS) (ADDRESS)
�(-7Z
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: Z3