Martin, Thomas OF QUEEN5BU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
'date Of Cremation \
Time Cremation Started \
Time Cremation Completed
Type of Container_j,}CQ
Remarks 41
A-1A
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08/20/2003 19:44 15074537877 PAGE 02
TOWN OF QUE kNSBURY
PINE VIEW CEMETERY
8�
CREMATORIUM
Quebec Roes,Quesnebury, Now York 1 ZW
Phone(w a)crematorium r4s-477(if no wwwer)
Cernster)►74S,4q.76
AUTHORIZATION TO CREMATE
The undersigned requests and euthorhms Pine View Cmmetoriurn.in acewordaW Iend oubjeCt
to its Rules and Regulations to Cremate the remaitM Of
(NAME:)
(8TRI;ET) (CITY) (STATE) (ZIP
who died on go YX day of s- 20
Alev-
(P=3015 (ADDRESS)
t w and addrm of nearest 9vmq relative or name of person authorizing
Rehkxiship th deceaoed A&if+
Now of Funeral Home in el e O
P"RTANT
I represent that to the brwst of my knowledge,the deceased bn or in his or W
body. (CIRCLE 01`44
I ox"that I have the full power and authorization~to arrange for the crerummw mm i rernafns and
to direct the disposition of the a'emeW remains,that any persona) eltlrer been
r pNed yr may to destraymij and agrw*to protect,deft xi and too view
,CrwrA6m ium from eny and all claims and dens ft for knee or'---s~ mods
against them by rsason of or connscWd with the marnstlat of said remains as .whether
such Maims or demands are or are not wholly groundless,False or fnRrduhrnt.
Et a) (ADDRESS) 11�1 bxa�F 51 S7
3`71
PURE OF RELATWOR LEOAL REP.AND AMMESS)
Signed on this date: •Zf Q3