Bailey, Sarah TO`wQ OF QUEEN,5BUQy
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4-477
Funeral Director Ji�N��, Etcl �y�i L,
ale_ f2�I-1 K} .�'�4iil�� Casey 3
ate Of Cremation - 4 —� — ZUc% t,1
Cremation Started
e Cremation Completed �� 3� y� /vx
. p e of Container. C,y4 F)-C) 13,,.4-0
��Tarks
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TOWN 01: QUL=E14SUUIIY �' Z
PINE VIEW_CEMETERY
CREMATORIUM
Quaker Road. Queerrsbury, New York 12UU4
Phone (G10) Crerr,►atorium 74G-•1477 (i1 no answer)
Ceinelery 745-4476
AU1'I-IO121ZA'l ION I U G ZEMA I E
The undersiyned requests and authudzes Nitre View I. 1211l tUrlUrrr. in accurdance with and subject
to it Rules and Regulations to cremate the remains of: 1
(NAME) (SL=X)
r Uv11c sr� a CD
(STREET) <J (Sl A l ) (ZIP CODE)
who died on 13 day of C 20-4
at "1 Ul� t
(PLACE) (ADDRESS)
Name rd dress of nearest living relative or name of person authorizing cremation:
Relationship to deceased ���
Name of Funeral Home 1 - �
IMPORTANT
I represent that to the best of my knowledge, the deceased has dr has i6 acemaker In his or her ,
body. (CIRCLE ONE)
I certify that I have the full power and authorization to arranye for the cremation of the remains and
to direct the disposition of the cremated rernains, 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)
(SIGNATQAE OF LATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: