Deisley, Virginia '77-lq+N OF QUEENBU
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
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Daft e 01 Cremation
Time Cremation Started � p - � � rA -'It
lime Cremation Completed
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Remarks
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TOWN OF OUEENSBURY ;z
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road. Queensbury. New York 12804
Phone t518) Crematorium 745-4477 (if no answer)
Cemetery 745-4476
AUTHORIZATION -10 CREMATE
The undersigned requests and authorizes fine View Lremalonum. in accordance with and subject
to its Rules and Regulations to cremate the remains of.
N 1, T
(NA ) (SEX)
(STREET) (CITY) (STATE) (ZIP CO OE)
who died on I day of ^/ rC w� I 20 7
at 0-�� /Ul
L6a4e�
(PLACE) (ADDRESS)
Na a and address of earest living relative or narne of person authorizing cremation:
3 3 Ltd Cc ,k\ �O
2
Relationship to deceased p
Name of Funeral Home u -1 �
IMPORTANT
I represent that to the best of my knowledge, the deceased has or has no pacemaker in his or her
body. (CIRCLE ONE)
1 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
Cremat num from any and all claims and demands for loss or damages which may be made
again them by reason of or connected with the cremation of said remains as directed, whether
su I 'm or man s are or are no holly gr undl false or fraudulent.
( ITNESS) (ADDRE S)
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(SIGNATURE /OF RELATIVE OR LEGAL P. AND ADDRESS)
Signed on this date: � CS�i