Currier, Clara �ormlN OF QUEENBU
-r�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURy NEW YORK 12804
(518) 745-4476 (518) 745-4-477
Funeral Director_ �F�N ��/�N �/
`;ame C�-Iqv-12'f CO V—Q�A &Q-.1
Case
Date 0[ Cremation O _ 2a,
2.d c}
Time Cremation Started
Time Cremation Completed
Type of Container
Remarks
I
C
TOWN OF QUEENSBURY
PINE VIEW CEMETERY& CREMATORIUM
Quaker Road, Queensbury, New York, 12804
Phone (518) Crematorium 7454477 of no answer Cemetery 7454476
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:
(Name) (Sex)
(Street) (City) (State) ( ip)
who died on � .__..
day of 20 c'�
(Place) (Address)
Name and address of nearest relative or name of person Authorizing cremation:
(Name) (Address) t—?�
Relationship to the deceased 5Q 1\1
Name of Funeral Home -016 l
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 or
connected with the cremation of said remains as directed, whether such claims or demands are or are not
wholly groundless, false or fraudulent.
(Witness) (Address)
(Signature of Relative or Legal Rep. and Address))
Signed on this date: