Turcotte, Eugene TURN OF QUEEN4,5BURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director lyt6 c>' 1=_
Name fi-0 R,cooyrt Case # ;? Z 0
Date of Cremation `S r1 ' ZOO koi
Time Cremation Started
Time Cremation Completed
Type of Container Go°►IP-6 j3br:4x)
Remarks :
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TOWN OF QUEENSBURY -71 -
PINE VIEW CEMETERY
&
CREMATORIUM
Quaker Road. Queensoury, New York 12804
Phone (518) Crematorium 745-4477 (if no answer)
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium. in accordance with and subject
to its Rules and Regulations to cremate the remains of:
�1^ OL e A C-- LAt c o v1J
(N E) (SEX)
(STREET) (CITY) (STATE) (ZIP CODE)
who died one day of
20 bL4
at—
(PLACE) DDR SS)
Name and address of nearest living relative or name of person authorizing cremation:
[�•zw'w�� IM ��Tz� �
Relationship to deceased
Name of Funeral Home
IMPORTANT
I represent that to the best of my knowledge, the deceased has o , as no pacemaker in his or her
body. (CIRCLE ONE)
I certify that I have the full power and authorization to arrange for the 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
su claim or demands are or re not wholl gro false or fraudulent.
A�
(WITNESS) (AD )
(SIGNATURE OF RELATIVE 0 LEGAL REP. AND ADDRES )
Signed on this date: Mti o�