Osuchowski, David �o� o F QUEEN U
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PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSgURY, N,FEW YORK 12804
(518) 745-4476 (518) 745-4-477
Funeral Director —,�,��j (�-T--Vs
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Casey
Dale Of Cremation — 20c)
T '- ^e Cremation Started M
7 ,me Cremation Completed
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I-OWN 01: QUEENSOURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road. Queensbuiy. New York 12604
Phone (518) Crematorium 745-4477 (if no answer)
Cemetery 745-4470
AUITIORIZATION TO CREMAI E
The undersigned requests and authorizes fine View GICIna1UHL1111. in accuidance with and subject
to itsRules
�and Regulations to cremate lire remains uf:
3 ' avw'cC a"rz� 0'-V'U�
( ME) (SEX)
/o/ �z / 3i
(STREET),' (C lY) (STATE (ZIP CODE)
who died on J-z day of 2067_'R
at
(PLAC F4 (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
jai l
Relationship to deceased
Name of Funeral Home 1✓ �`�%
IMPORTANT
I represent that to the best of my knowledge, the deceased has I has no acemaker 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 reasofl of or connected with the cremation of said remains as directed, whether
su ims or demagds are or are not wholly groundless, false or fraudulent.
(W N S (AD RESS)
(SIGNATUR F RELATIVE OR LEGAL RE. AND ADDRESS)
Signed on this date: /3�O