Crofut, Kristopher r-ro7+N OF QUEEN5BU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSgURY. NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral DDiirector_tA�
Name �f� • 3tp��1P� Get L) I, Case#
Date Of Cremation Zo0 ,r�
Time Cremation Started_ 11 All
Time Cremation Completed � � 'PeVL
Type of Container_ �f�I7� �,,��,� �✓� i � _ � 1 r� � ��
Remarks L
TOWN OF QUEENSBURY
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 Pine View Crematorium, in accordance with and subject
to its Rules and Regulations to cremate the remains of:
Kri stor_,her Crofut Male
(NAME) (SEX)
210 Fort Edward Road, South Glens Fals, NY 12803
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 3rd day of July 20 03
at his home
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Roberta Crofut, 210 Fort Edward Road, South Glens FAlls, NY 12803
Relationship to deceased Wife
Name of Funeral Home M.B. Kilmer Funeral Home, 136 Main St. SGF
IMPORTANT
I represent that to the best of my knowledge, the deceased has r gasnpacemaker in his or her
body. (CIRCLE ONE) _
r
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. i
. y
(WITNESS) (ADDRESS) `
(SIGNATURE OF R LA IVE R LEGAL REP. AND ADDRESS)
Signed on this date:
i
p