Fox, William TOTS OF QUEE9�50Ur�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745.4477
Funeral Director
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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 IT APPEARS ON THE BURIAL-TRANSIT PERMIT
2. DATE THE BODY WAS DELIVERED
3. NAME AND LICENSE NUMBER OF FUNERAL DIRECTOR OR UNDERTAKER
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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 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
SOWN OF QUEENSBURY
PINE VIEW CEMETERY&CREMATORIUM
Quaker Road, Queensbury, 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 theremains of:
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(Name) (Sex)
(Street) (City) (State) (zip)
who died on �� '—'`� day of btu 20 O 3
at Lx>1 �.O's .>0L..
(Place) (Address)
Name and address of nearest relative or name of person Authorizing cremation:`
(Name) e7 (Address)
Relationship to the deceased iy3> F,
Name of Funeral Home
IMPORTANT:
I represent that to the best of my knowledge, the deceased has o oa�npacemaker 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 groundless, false or fraudulent.
Witness (Address)
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elative or L gal Rep. and Address))
Signed on this date: Z)Z3)