Godzisz, John rr0J4N OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director d — '-e10llu
Name JcSh,,� �� �,p� z , �Z Case #
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Date of Cremation
Time Cremation Started Sp
Time Cremation Completed V
Type of Container Cc"o� tom'G., yv\o `n on
Remarks :
Craw 1�rj ISM- Case OC m
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TOWN OF OUEENSUURY L,
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PINE VIEW CEMETERY
CREMATORIUM
Quaker Road. Queeiisbuty. New Yuik 120U4
Phone (510) Cremploiium 740-•1477 tit nu answer)
Cemelery 745-447U
- . AUITIORIZA I ION 'I V k;HL:MA I L
The undersigned requests and aulhuiizes Dine ViUW UILI UtU11U111. in accuidance with and subject
to i Rules and Regulations to cremate the iei tali s ul:
• (NAME) t-g -/X)s/-�-y� { 6a4LI
(STREET)
n ,Q CI I ) (S I A I L) /(ZIP CODE)
who died on ! sue` day ui ` 2p
at A16n-lel-1
(PLACE (ADDRESS)
Name and address of nearest living relative or name of ue►sun authorizing cremation:
�ac� 2isz
Relationship to deceased S oov
Name of Funeral Home i `I U► I
IMPORTANT
I represent that to the best of my knowledge, the deceased has or 11 i1v 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 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
su c s r I rids are or are no wholly grounds false or fraudulent.
TNESS) (ADDRESS)
(SIG E OF REELATIVE O LEGAL REP. AND ADDRESS)
Signed on this dale: • /