Potter, James roMN OF QUEENBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
m e 1�/l Cj S T" l \ l �Z Case;: 3
mate Of Cremation
Time Cremation Started
Time Cremation Completed
. ype of Container 164tZ� 06oa OKECW6K151 /Viy) i-tlA I D
Remarks
TOWN Of- OUEENSOURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road. Queensbury, New York 12804
Phone t518) Crematorium 745-4477 (if no answer)
Cemetery 745-4476
AUTHORIZATION ]0 CREMATE
The undersigned requests and authorizes fine View ClernatUnUrrl. m accurdance with and subject
to its Rules and Regulations to cremate the remains uC
kn� J
NAME) (SEX)
Ax �o
(STREET) (CITY) (STATE (ZIP CODE)
who died on day of 1 20a-A
at
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Relationship to deceased. p
Name of Funeral Homez,,az//� - An�/� 4- �Z .
IMPORTANT
I represent that to the best of my knowledge, the deceased has or ias 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 or connected with the cremation of said remains as directed, whether
such claims or demands re or are not wholly groundless, false or fraudulent.
(WITN S) ESS)
T OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed 6n this date: