Ballard, Larry TO OF QUEEN,
,5BUP. y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4-476 (518) 745-4477
Funeral Director
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Of Cremation � _ t"� _ 2Lf
:^ e Cremation Started
' : T.e Cremation Completed
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TOWN OF OUL=E14SUUIIY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road. Queeiisbuiy. New Yoik 12UU4
Phone (510) Crernatoiium 7,15-4477 (il no answer)
Cemetery 745-4470
AUTI-10RIZA1 ION 'IQ UREMA I E
The undersigned requests and authorizes Nine View Giumatumml. in accuidance with and subject
to its ules and Re lions to cremate the iemaiiis W.
CL,f I-�A 0—\ \Ou�� LQQ=�C,-
c�
SAM �4 c�T lap
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(STREET) (CI-IY) (S I-A-I E) (ZIP CODE)
who died on I J day of _Yna,�C- 2oLq
at '35 G "'\n\.� �
(PLACE) (ADDRESS) j� v
Name and address of nearest living relative or name of person authorizing cremation:
Ci 4 I ICIAafu 4 -
Relationship to deceased
Name of Funeral Home �OY\" �►`
IMPORTANT
I represent that to the best of my knowledge, the deceased has (th
as no cemaker In his or her
body. (CIRCLE ONE)
I certify that I have the full power and authorization to arranye (o 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) (ADDR SS)
L
(SIG URE OF�LAWIVEOR LEGAL REFS. AND ADDRESS)
Signed on this date: • JI ,LP 1 ��