Beaty, Donald TO rNN OF QUEEN�BU-r�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 1
Case;- _
Date Of Cremation
Time Cremation Started D
T '7e Cremation Completed
T , pe of Container �� ,�� �� ,� ��-\1A
Remarks
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TOWN 01: QUEENSBURY 03 C
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury. New York 12804
Phone t518) Crematorium 745-4477 (if no answer)
Cemetery 745-4476
AUTHORIZATION '1 O CREMA1 E
The undersigned requests and authudzes line View Lieniatunurn. in accurdance with and subject
to it Rules and Regulations to cremate the remains uli
am-d— L"
(NAME (SEX)
/J
(STREE��T��) (CITY) (STATE) (ZIP CODE)
who died on .�d �A day of �l 2003
✓� U r/J •
at
(PLACE) (ADDRESS)
Name d address of nearest
living relative or name of person authorizing cremation:
Relationship to deceased
Name of Funeral Home JUL",',
IMPORTANT
I represent that to the best of my knowledge, the deceased has r I�aS 11 cemaker 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)
(SIGNATU E OF RE OR LEGAL REP. AND ADDRESS)
Signed on this date: 1 z��