White, Gerald To,wN of QUEEN,5BUPJI*"
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745.4477
Funeral Directoc j/ (c C,Lr /-ki),-�
Casey
-;ate Of Cremation
T 'r,e 1 ,
Cremation Started
.. i'r.e Cremation Completed
e of Container 0�1-\1-d �-� NL f a, 9 `,3 o A
remarks
�� I G iA ,; r A40 A/-' J6
J8/'?3/20F rJ OJ: 1� 516-7 3 -d 174 i L' -Itt riv r,
(TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker road, Queenibury, New York 12804
Phone/5tt3�Cr ematorium 745-4477 (it no answer)
Cemetery 745-4476
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AUtHORI7ATION TO GREMATL
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The undersigned requests and authorizes pine View Crematorium, in (accordance with and
subject to its Rules and Reyulation to cremate the remains of.
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tr�AME! i (SEX)
_pgvlr ,0-- �o �gle ,vy 1�2fz_
(STREET) ((;l Y) (STATF) (ZIP GOUE)
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who died on�? 1 �` I —day of tog
at__1JGvGvy � }} --- d�iQLt!_/j/� -—��— -- �/i�1'1•�►�/�OAIQ
(PLACr t (AC1 RESS)
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Name:end address o`nearest living�elative or narne of person eulhoriz rig cremation;
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Relationship to deceased
Name of Funeral bore AkG WO1/ /�if/�it4rj/✓mo4007
!'C'e
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IMPORTANT
I represent that to the best of my knowledge, the deceased h-as or Us no pacemaker in his or tier
body. (URCLE ONE)
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I certify that I have the full power an authvrization to arrange tr,r the crernatacx7 of the remains
and to O'ect the disposition of the cipni?tod remains, that any uerional possessions have either
been removed or ma r to destroyed.land agree to protect, delenJ and sa•,e harmless fine Vie'h
Crernatoriurn horn any and all claim and demands for loss or as rages which may be made
agalns!them by reason o`or connected with the cremation of sa+d r'ernain,, as directed,vvhellter
such -,la s or drImands �e r h ply groundless, false or fraur!llent. 2�
biTNFS ) ESS C Cj --� — i
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(SIG, A R C EL4TlV: CAR l-LGKI Rfi' AND ADDRf -S5)
Signed on this date.__o� — —
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