Abare, Lloyd zoo �C OF, QUEENs5BU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director tl)� 13 W � I'M L Ll
Name �� (5�(�' C Case"
_Jame Of Cremation C?
Time Cremation Started d
Time Cremation Completed
Type of Contai nerc aa. VLA4)Zj
Remarks
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2 IT,
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 Ru
les and Regulations to cremate the remains of:
X•
(NAME) (SEX)
W /
(STREET) (CITY) (ST ) (ZIP CODE)
who died on 7///0,3 day of 20
at
(PLACE) W ad-1
(A RESS) pa
Name and address of nearest living relative or name of person authorizing cremation:
Relationship to deceased_
Name of Funeral Home _
IMPORTANT
I represent that to the best of my knowledge, the deceased has or has no 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 from any and all claims and demands for loss or damages which may be made
against them by reason of 6r connected with the cremation of said remains as directed, whether
such cla' s or man s are or are no holly group s, Ise or fraudulent.
(WITNESS) (ADDRESS)
(SIGNATURE OF RELATIVE OR LEGAL REP. AND DRE )
Signed on this date:_ //J1U3