Blair, Walter TOTS OF QUEEN,,,5BUP,,_y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director S_=Q1P Lays _ Ct�GC
1z Casey:
-ate Of Cremation tl
Time Cremation Started
' iTe Cremation Completed Z�
. "'De of Container cc,& MCL,n 0A IL 'as (40,
Kemarks
C)�
Coo
TOWN OF QUEE14SUUIIY
PINE VIEW CEMETERY
3.
CREMATORIUM
Quaker Road. Queerrsbury. New Yurk 120U4
Phone 1,510) Creniatodum 7.15-4477 (it no answer)
Cemetery 745-4470
AUTI-10RIZA11ON *10 CREMA I E
The undersigned requests and authorizes Nine ViUW C1131natununr. in accordance with and subject
to its Rules and Regulations to cremate the remains ul:
(NAME)
(STREET) (CITY) (S IM L•) (ZIP CODE)
who died on day of L>YCd A'2 20�
II (
at ic5 ,;(s s p, r , (� UO A;e-K �t• I�YIS �S
(PLACE) (ADDRESS)
Name an address of nearest living relative or Hanle o1 pe
rs
on aullroriziny c malio�nj:
L' ia�ii4 ��r'��2 �� � oe%C• y� :,�t�Su
Relationship to deceased
Name of Funeral Home %� � � �� 1.r2Q �►'��
IMPORTANT
I represent that to the best of my knowledge, lire deceased has or as rro cemaker In his or her
body. (CIRCLE ONE)
I certify that I have the full power and authorization to a►ranye for the cremation of the remains and
to direct the disposition of the cremated remains, that airy 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
su501pims or dem n re or are not wholly groundless, false or fraudulent.
7-'e'z:z--z
NESS ADDRES
IV (SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this dale: