Laraia, Rita OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director SylriyC"^ Mi' IQY`%n — Po,4+,.ef—
Name e:; ' Case #
Date of Cremation
Time Cremation Started 6 o Awl
Time Cremation Completed
Type of Container (f'-qjj000-j rvia.14 ovj 10 : oS p,,7
Remarks : Q
mv✓ect 11 bo A wt
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TOWN OF OUEENSUUI1Y
PINE VIEW CEME•1'EIZY '
CREMATORIUM
Quaker Road. Oueeiisbuiy. New Yuik 12OU4
Phone (510) Cren)oloiium 7,IG-4477 (il nu answer)
Cemelery 7.16-4470
AUITIORIZA]ION '1 U U11EMA I E
The undersigned requests and aulhuiizes fine View Ciemaluimm. in accuidance with and subject
to its Rules nd Regulations to cieinale the ieniaiiisii
Cl G
(NAME) (SEX)
q rn3 )q A i we- C
(STREET) (CrI ) (S I A 1 E) (ZIP E)
who died on day of U / 206-L-Z
at -4)rnC-'- 17 c( 3 ,b
(FA CE) (ADDRESS)
Name and address of nearest living relative or name of heison authorizing cremation:
Relationship to deceased Huabfiwo
Name of Funeral Home S Gv nJ L
IMPORTANT
I represent that to the best of my knowledge, the deceased has o Kira r1 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 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 creniatiort of said remains as directed,whether
such claims or demands are or are not wholly groundless, false or Iraudulenl.
(WITNESS) (ADDRESS)
( IGNATURE OF RE TIVE OR LEGAL REP. AND AUUIZESS)
Signed on this date: