Baker, Gerald To gtiN OF QUEE9. 50U-r�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4.477
/� Funeral Director Sri P
`.a—e l0rc.W 9,,Kec- CaseF
�a : e Uf Cremation a
�.G Cremation Started 7.:
T:e Cremation Completed
„e of Container CC,r a 0r ISt <<, e v
s f� c�w Craw4,r
Turks
® 0
�: �� �,47
l'OWN 01: QUEE14SBUIIY
PINE VIEWSCEME'I'ERY
CREMATORIUM
Quaker Road. Queeiisbuiy. New York 12804
Phone (518) Creinalmium 745-4477 (if no answer)
y Cemelety 745-4476
AUITIORIZA'I ION 10 C HEMAI E
The undersigned requests and aullmizes Dine View GleMaIWIL1111. in accuidance with and subject
tots Rules and Regulations to cremate the remains ul:
t �
(NAME) \ (SEX)
(ST ET) (CITY) (S l'A 1 E) (ZIP CODE)
who died on
I dayat
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
[:% a
Relationship to deceased �S TC�.►�
Name of Funeral Home VGr--,, - I cy �r t-'�-�-� ►'
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 arranye for lire 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
suctrclelgiso,r,demands are 74a6112A
re not wholly groundless, false or fraudulent.
�c19
(WITNESS) (ADDRESS)
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: