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Ely, Gerald TO"WN OF QUEEN,5BUJ�y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director e I*J'1 e R,t -4j C a s e;; `ate Of Cremation I <e _ L Cremation Started ' i e Cremation Completed oe of Container0-1&, I �1 141 _ F)0 A�,,1 _marks TOWN 01: QUEENSUU11Y l? PINE VIEW CEMETERY 3. CREMATORIUM Quaker Road. Queensbuiy, New York 12t1U4 Phone i510) Creiriatodum 7,15-•1477 (if nu answer) Cemetery 74G-4476 AUTI IUI�IZA'I ION I U C:Itt_MA I E The undersigned requests and authudzes Ville View ClerllatWIL1111, in accuidance with and subject to its X'-aPqC1> s and Reyulations to cremate (lie remains ul. l- A #z,c (NAME) (SEX) laRV (STREET) (CITY) (S I A I E) (ZIP CODE) who died on ' Z(�(�i��/ �� _day of //11Cf�1 20 ©� at�L�� (PLACE) (ADDRESS) Name and address of nearest living re alive or name of person authorizing cremation: Relationship to deceased ZO/�C Name of Funeral Home )n �. 7'l (, lur✓i`�ZR-C� Ja-me 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 arranye for lire 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 suc laims or demands;sre or are n t wholly groundless, false or fraudulent. (WITNESS) (ADDRESS) A2-2�' a�t�0..�,��Q+- (SIGNATURE OF RELATIVVOR LEGAL REP. AND ADDRESS) Signed on this date: • �� d�