Hall, Roger rrO q4N OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director kneel{• t)n - Y-calv
Name Qp �y�(j Case # I (o
Date of Cremation /-pJ- appLj
Time Cremation Started 10 10 �n1
Time Cremation Completed 06 fyl
Type of Container Car-d&),.ram( Mg-.,, oil j 0' 3® t�,yI,i
Remarks : l
('c uwj 1 $,4 CaSe
%Oaajed- 00 pwl
i� y5 fir►-,
[ "06 �►�
TOWN Of OUEENSUURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road. Oueerrsbury. New Yoik 121304
Phone 1510) CrerilatUrium 7.15-4477 (if no answer)
Cemetery 745-4470
AUTHORIZATION 10 UREMAIE
The undersigned requests and authorizes Dine View ClellralUM1111. in accuidance with and subject
to it ules and Regulations to ciernale_the remains ur.
�. M
(NAME) (Sl X)
l!� Z
(STREET) (CITY) (S1 Al E) ( P C DE)
who died on day of 04
at lL
LACE) (ADDRESS)
Name and address of near t living relative or name of person authorizing cremation:
�l.t.
Relationship to deceased
Name of Funeral Home
IMPORTANT
I represent that to the best of my knowledge, the deceased has or 1as 11 pacemaker 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
aga st them , y reason of or connected with the cremation of said remains as directed,whether
s s de�c�ands are or are not wholly groundless, false or fraudulent.
l2
(WITNESS) (ADDRESS)
(SitNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: C.�-