Williams, James TOTIN OF QUEE9\�50UP\ y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 74 5-4477
Funeral Director 1�1 . a,Ker
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PINE VIEW CEMETERY AND CREMATORIUM ,
RECEIPT FOR BODY PURSUANT TO NEW YORK STATE PUBLIC
HEALTH LAW SECTION 4145(2)(B)
1. NAME OF DECEASED AS IT APPEARS ON THE BURIAL-TRANSIT PERMIT
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2. DATE THE BODY WAS DELIVERED
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3. NAME AND LICENSE NUMBER OF FUNERAL DIRECTOR OR UNDERTAKER
4. FUNERAL FIRM REPRESENTED BY FUNERAL DIRECTOR OR UNDERTAKER
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5. NAME OF PERSON IN CHARGE OF CEMETERY
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6. SIGN URE OF FUNERAL DIRECTOR OR UNDERTAKER
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7. SIGNATURE OF PERSON IN CHARGE OF CEMETERY
8. NAME OF CEMETERY EMPLOYEE WHO RECEIVED BODY
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9. SIGNATURE OF CEMETERY EMPLOYEE WHO RECEIVED BODY
TOWN OF QUEENSBURY \
PINE VIEW CEMETERY -J \
&
CREMATORIUM '
Quaker Road, Queensbury, New York 12804
Phone (518 ) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium in
accordance with and subject to its Rules and Regulations to cremate
the remains of:
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(Name) (Sex)
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C �-7- �� d situ ZF �—
(Street) (City) (State) (Zip C de)
who died on day of Tsr-- -jj�
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(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
(Name) (Address)
Relationship to the deceased i -S i L�
Name of Funeral Home�,�l ,� L'-
IMPORTANT:
I represent that to the best of my knowledge, the 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 them by
reason of or connected with the cremation of said remains as
directed, whether such claims or demands are or are not wholly
gro less, false or fraudulent. ,p Xl x
7
(Witness (Address) ,
(Signatu/rA of ReV
ative or Legal Rep. and Address)
Signed on this date: -(� e