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Hillis, June �0WN OF QUEEN,5BU9�y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director < Name ` �uh� ��. �(. Case?# � r75 Date Of Cremation :10p3 Time Cremation Started_ It ."(© ,� Time Cremation Completed J , Type of Container CAad�u,�r�,l Remarks C(-Aj(�mt-d 3 PJ cA,.e f. mom", o n l 4S xx W% em JV 'PY✓1 � ES Pam. 13 0 LtS �►� a oy Pw, TOWN 01: QUEENSBURY aC�5 PINE VIEW CEMETERY CREMATORIUM Quaker Road. Queensbury, New York 12804 Phone (518) Crematorium 745-4477 (if no answer) Cemetery 745-4476 AUTHORIZATION TO CREMATE The undersigned requests and authorizes fine View Crematorum. in accordance with and subject to its Rules and Regulations to cremate the remains of. -��Q ' t. (NAME) (SEX) Qd I Z& 6V (STREET) (CITY) (STATE) (ZIP CODE) who died on 3 day of 20 L/) at _) Ult.t~ (PLACE) (ADDRESS) Name and address of nearest living relative or name of person authorizing cremation: Relationship to deceased �Y—��-1� ACC - -�7 "✓a'z1C Name of Funeral Home I try - Fo-edlL � IMPORTANT I represent that to the best of my knowledge, the deceased has or has no 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 connected with the cremation of said remain§as directed, wheth r such claims or demands are or are not wholly groundless, fall d nt. (WITNESS (ADDRESS) ol (SIGNATURE OF R LATIVE OR LEGAL REP. AND ADDRESS) Signed on this date: 3 2 1