Lynch, Laura �o OF QUEE9 5BU-r�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4.476 (518) 745-4477
Funeral Director__
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dace Of Cremation - 2Ce- - � 2
' '-me Cremation Started_
Time Cremation Completed
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I"OWN 01= OUEENSDURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road. Queensbury, New York 12804
Phone t518) Crematorium 745-4477 (if no answer)
Ceinelery 745-4476 g
AUTHORIZATION I O CREMAI E
The undersigned requests and authorizes Mine View Giematuriurn. in accurdance with and subject
to its Rules d Regulations to cremate the remains ul:
(NAME) (SEX)
(STREET) ( IlY) (S"tATE-) (ZIP CODE)
who died on 21 day of 20 _
at
(PLACE) (ADDRESS)
Name and address of�nearest living relative or name of person authorizing cremation:
Relationship to deceased / 4�
Name of Funeral Hom 2 oe�
IMPORTANT
1 represent that to the best of my knowledge, file deceas I�as I acernaker 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
suc claims or demand re or are not wholly groundless, false or fraudulent.
(WIT)4E ) (ADDRES )
SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date:
SULUvAN-1VI1J"HANA VQW t ORAL BOON Ala
�st� -aeo�e�►
"Customer's Designation of Intentions"
Name of Deceased.: C ✓ .
Cremation:
(Scheduled Date) (Location)
Manner of Disposition of Cremate Remains:
F(Burial at ❑ Return to Family
❑ Entombment at ❑ Other (specify):
I hereby designate the Disposition of Cremated Remains and acknowledge receipt of a copy of
this form.
71
(S(i�gnat�rel J 1
(Printed Name) (Relationship to Deceased)
(Address)
(Telephone Number)
"Cremated. Remains which shall not have been claimed within 120 days from the date of
cremation may be disposed of by this firm by placement in a columbarium."
J
Printed Name of Funeral Director Sign o Funeral Director Date
or Undertaker or Undertaker
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS
Cremation:
(Actual Date) (Location of Crematory)
Disposition of Cremated.Remains:
(Manner of Disposition)
(Location)
(Date)
Name of Person Makings Disposition Signature Date
#9 WHITE:Funeral Home Copy YELLOW:Family Copy PDM:Crematory Copy CUSDUEN Rev.V96