Conrad, Joann ZO�tiN OF QUEE9�5BUPY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745.4-477
Funeral Director
CCA Rc-� C a s e y � L i
ace Of Cremation
=�^e Cremation Started
' !Te Cremation Completed l '�
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remarks
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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 ITAPPEARS ON-THE',BURIAL-TRANSIT PERMIT
70 PrN N Co N R )g
2. DATE THE BODY WAS DELIVERED
3. NAME AND LICENSE NUMBER OF FUNERAL DIRECTOR OR UNDERTAKER
4. FUNERAL FIRM REPRESENTED BY FUNERAL DIRECTOR OR UNDERTAKER
5. NAME OF PERSON IN CHARGE OF CEMETERY
w
6. SIGNATURE OF FUNERAL DIRECTOR OR UNDERTAKER y
7. SIGNATURE OF PERSON IN CHARGE OF CEMETERY
8. NAME OF CEMETERY EMPLOYEE WHO RECEIVED BODY
9. SIGNATURE OF CEMETERY EMPLOYEE WHO RECEIVED BODY
.
TOWN OF QUEENSBURY ,JS ✓
PINE VIEW CEMETERY& CREMATORIUM
Quaker Road, Queenshury, New York, 12804
Phone(518) Crematorium 745-4477 of 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:
(Name) (Sex)
)4''L_I fit UGr'► r r o2i rrtitAK"t" «S-a�r
(Street) (City) (State) (Zip)
who died on �,u ` 1k day of 1���P�_ 20 o3
at iq�A Sf--krZAtcC1F� (L). ) ,
(Place) (Address)
Name and address of nearest relative or name of person Authorizing cremation:
lhlt Li,i&/n 1 i5A-e,(V�U All Gv&T OV1 . Ea al L5b W&9_6 hf. ,
(Name) (Add ess)
Relationship to the deceased scrip!
Name of Funeral Home t2L;(;hAl f�L Nd Y
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or has no pacemaker in his or her body.
(Circle One)
1 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 br are not
wholly groundless, false or fraudulent.
(Witness) (Address)
(Signature of Relati a or Legal Rep. and Address))
Signed on this date: