Cronkhite, Elaine TOrwN OF QUEE9�5OUr•
PINE
INE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477-
Funeral Director6/,� �, ,,ly14
` aTe � G>� fi >~, Case
ate Of Cremation �- 2-4 ,Zoo u
=�.c Cremation Started c,C6
' ime Cremation Completed
Pe of Container �� �yg f
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TOWN OF QUEE14SLJUiIY e(�
PINE VIEW CEMETERY v
CREMATORIUM
Quaker Road. Queensbuiy, New York 12004
Phone t510) Crematorium 745-4477 (if no answer)
Cemetery 745-4476
AUITIORIZATION '1 O C REMA I L=
The undersigned requests and authorizes I-Iine View Ciematuiiuin. in accuidance with and subject
to its Rules and Regulations to creniale the remains ul:
(NAME) (SEA)
(STREET) l� (CI-IY E)) (S i�A�I IP CODE)
who died on C i day of Q.� Zp
at G-4- �1 ]D,
(PLACE) I (ADDRESS)
Name and ad ress of nearest living relative or name of person authorizing cremation:
( 6Y) L
Relationship to deceased 1 J�^"`"-►
Name of Funeral Home lO
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 arra►rye for(lie 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)
l
(MI NATUFTE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: o