Spaulding, George TOTvN OF QUEEN
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PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 74 5-4477
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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 130a 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
6. SIGNATURE OF FUNERAL RECTOR OR UNDERTAKER
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 - G
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensoury, New York 12804
Phone (518) Crematorium 745-4477 (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:
( ME) (SEX)
scvo-1 / I A 331
(STREET) (CITY) (STATE) (ZIP CODE)
who died on LIl day of 0 V c- "A 20 v
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of
person authorizing cremation:
Relationship to deceased
Name of Funeral Home ✓1S M a� e rc o,,P f`�
IMPORTANT
I represent that to the best of my knowledge, the deceased has o has no pacemake 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
su Iai or demands re or are not wh oundless, false or fraudulent.
(WITNESS) Aver" ^
(ADDRESS)
)'f��i�(SI�GNATUREPP RELATIVE OR LE REP. AND ADDRESS)
Signed on this date: ?Z 3 D 6