Herschleb, Marjorie ' or +N of QUEEVBU-r�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Date of Cremation
?=Te Cremation Started
Time Cremation Completed
. ype of ContainerOK-\?-()
Remarks
SINGLETON-HE4 ALY FUNERAL HOME
407 Bay Road
C ueensh",NY 12804
(5I8)793-4.459
"Customer's Designation of Intentions"
Name of Deceased.:
Cremation: 3.=t c- ,;ti ..... ti J •..� } v .t
(Scheduled Date) (Location)
Manner of Disposition of Cremated. Remains:
❑ 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.
l((Signature)
(Printed Name)" (Relationship ip to Deceased)
(Address)
(Telephone Number) t
"Cremated Remains which shall not have been claimed. within 120 clays from the date of
cremation may be disposed of by this firm by placement in a columbarium."
t
Printed NAae of Funeral Director ,Sig a re of 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)
of Person Making Disposition ,Signature Date
eral Home Copy YELLOW Family Copy PINK:Crematory Copy CUSINTEN Rev.V96
TOWN OP OUEENSBURY 776
PINE VIUW CEMETERY
CREMATORIUM
Quaker Road. Queensbuiy. New York 12804
Phone t516) Crematorium 745-4477 (if no answer)
Ceineteiy 745-4476
AUITIORIZATION 'I O GREMA-1 E
The undersigned requests and authudzes Dine View Glelnalulll11I1. in accuidance with and subject
to its Rules and Regulations to cremate the remains ul.
�►�1 ate
( t bE) (SEX)
-3\ - C-�t �a��
(STREET) (CI"iY) (S"AI-E) (ZIP CODE)
who died on day of 'Ec� 20
atQ--
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Q�
Relationship to deceased
Name of Funeral Home S"&—hh
IMPORTANT
I represent that to the best of my knowledge, the deceased has leas nv 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)
)(7�SIG�NATLI'REOF RELA4VVEO ftAL
Signed on this date: • C S