Goldman,Saul rn cMIN OF QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name S'44-1 k fXQv%k3� Case # 3 L4 L4
Date of Cremation — -?- 1Z — 7 aaq
Time Cremation Started Cl 4 /lid
Time Cremation Completed 1
Type of Container(JIhQ 2 bL -� d 'ILA0 A 4-1L
Remarks : I
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TOWN OF QUEE14SUUIIY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road. Queeiisbuiy, New Yolk 12UU4
Phone t510) Creinaloiium 7,15-4477 (il nu answer)
Cemetery 7,15-4476
AUI I-IO121ZA'I ION 10 GRLMA I L=
The undersigned requests and aullwiizes I-11ne View l,ielnalunu111. ill accuidance with and subject
to its Rules and Regulations to cremale.lhe remains ul.
sa_'�J G-D I '
a�
(NAME) : ���Vt��•(SLX)
O Ocher Iev
(STREET) (CITY) ( I A I L) (ZIP CODE)
who died on �O day of 20
o
at
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person autliorizirig cremation:
Relationship to deceased
Name of Funeral Home
IMPORTANT
I represent that to the best of my knowledge, the deceased has o haJ11 pacemaker In his or her
body. (CIRCLE ONE)
I certify that I have the full power and authorization to arrange for 11alion 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, delelld 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
such claims or demands are or are not wholly groundless, false or fraudulent.
(WITNESS) (ADDRESS)
(-k A-A &� 1" YyNa M I
(SI ATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: O