Guy, Anna TorWN of QUEEN,50U�Ky
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4-476 (518) 745-4-477
nFuneral Director
_ate Of Cremation
Cremation Started
' .-e Cremation Completed 1�, 26
e o l C o n t a i n e rc v TzTz 00 +4v:k) 6110 t�l�
remarks
rl L) '5
TOWN Of- OUEENSUURY
PINE VIEW CEMETERY 4
CREMATORIUM
Quaker Road. Queensbury. New York 12804
Phone (518) Crematorium 745-4477 (if no answer)
Cemetery 745-4476
AUTHORIZATION '10 CREMAI E
The undersigned requests and authorizes Dine View Giemalurrum. in accurdance with and subject
to its Rules and Regulations to cremate the remains ul:
(NAME) (SEX)
(STREET) (CITY) (STAI"L=) (ZIP CODE)
who died on QCT day of 200
at d/eWS klll_145/9,11)n PIU-L
(PLACE) (ADDRESS)
zand address of nearest living relative or name of person authorizing cremation:
Relationship to deceased (��.
Name of Funeral Home S/,45&rmn —1k?yLi -?i kw ogz-
IMPORTANT
I represent that to the best of my knowledge, (lie 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 em b eason of or connected with the cremation of said remains as directed, whether
such c e nds are or are not wh ly groundless, false or fraudulent.
7 � l
(W rrN (ADDRESS)
(SIGNATURE OF RELATIVE AND ADDRESS)
Signed on this date: •