Casabonne, Peter OF QUEENsBU
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEw YORK 12804
(518) 745-4476 (518) 745-4477
? Funeral Director "I c, ))/,R/y�OT=
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Date Uf Cremation
=me Cremation Started_ Ael
T ?Te Cremation Completed
T a e Of C o n t a i n e r cIr4\Q d Dr)y4 i2o/1
Remarks
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10 N1/2.Er'13 12:52 E18-732-1287 BEGAN&UENNY #1346 PAGE 01
TOWN OF QUEENSBURY
PINE VIEW CEMETERY 8,CREMATORIUM
Quaker Road, Queensbury, New York, 12804
Phone(518)Crematorium 745-4477 of no answer Cemetery 7454476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in Accordanw with and subject to its
Rules d Regulations to Cremate the remains of:
(Name) (Swo
Ile
(Street) (City) (State) (?in)
7 who died on c> --- day of
at
W (Place) (Address) '
Name and address of nearest relative or name of person AL:thorizing cremation:
(Name) Address
l
Relationship to the deceased lit/
Name of Funeral Honie__- ��
IMPORTANT,
i
I represent that to the best of my knowledge,the deceased has or has no pacemaker in his or her body. I
(Circle One)
I certify that I have the furl 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 directeo,whether such oiaims or demands are or are not
Lwhoground1piss,089 uduless) I Z
ss)
(Signature of Relative or Legal Rep. and Address))
n
Signed on this date:lG
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