Wiedl, Joseph TOZIN OF QUEEN5BU
�-y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 128C4
(518) 745-4476 (518) 745-4-477
Funeral Direc [or -5j�,/�,(/_-fyn) la�� C,1
Casea
are Of Cremation
Cremation started
Cremation Completed
D. e of Container Ci41 J3aAN-2L)
.T:arks l
' I
o `1
PINE VIEW CEMETERY AND CREMATORIUM
t
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
2. DATE THE BODY WAS DELIVERED
3
3. NAME AND LICENSE NUMBER OF FUNERAL DIRECTOR OR UNDERTAKER
4. FUNERAL FIRM REPRESENTED BY FUNERAL DIRECTOR OR UNDERTAKER
-7- ,
5. NAM6OFERSON IN CHARGE OF CEMETERY
6. SICOKTURE OF FUNERXL DIRECTOR OR UNDERTAKER
7. IGNATURE OF PERSON IN CHARGE OF CEMETERY
8. NAME OF CEMETERY EMPLOYEE WHO RECEIVED BODY
G v41a. `-. 6-T.vN N +
9. SIGNATURE OF CEMETERY EMPLOYEE WHO RECEIVED BODY
TOWN 01: OUL=ENSBURY
PINE VIEW CEMETERY .�
CREMATORIUM
Quaker Road. Queensbuiy, New York 12804
Phone t516) Crematorium 745-4477 (it no answer)
Cemetery 745-4476
AUITIORIZA FION I O CREMA I E
The undersigned requests and aulhu►izes Dine View Ciematumm. in accuidance with and subject
to its Rules and Regulations to cremate the remains ul.
VLy---i---P1a c IE i7C_ 1y1CAX
(NAME) - (SEX)
(STREET (CITY) (S I'Ai L=) (ZIP CODE)
who died on day of -Qp-e"vj"eA 20at (� �M, RP116 &--
—��
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
1
Relationship to deceased
Name of Funeral Home 's I r4s C D-v-� - UA
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 crernation 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.
(WTNES ) (ADDRESS)
(S
!fiMATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Sig �d on this date: 17,1203