Dudley, Joseph rrO q4N OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director '5'- /yL
Case #
Date of Cremation
Time Cremation Started
Time Cremation Completed -j V
Type of Container 'J�-1�� 2� 4AV1 ik'L. 1 l�
Remarks :
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2-,-T-T�
TOWN OF OUEEIJSUUIIY
PINE VIEW CEMETERY 2
CREMATORIUM
Quaker Road. Clueensbury. New Yuik 12UU4
Phone %510) Crernaloiium 7,15-•1477 01 nu answer)
Cemetery 745-4470
AU 11-101217J�1ION IU C:ItLMAIL
The undersigned requests and authudzes Dine View Giunwluimm. in accuidance with and subject
to its Rules and Regulations to cremate the renraiirs ul.
_Ge� P. e�2" 224 z:25=
AME) (SLX)
1z
(STREET) (CITY) (S I i t_ (ZIP CODE)
who died on day of 20C�
at 4AP
(PLACE (AD'DI AESS)
Name and address of nearest living relative or name of peisun authorizing cremation.,
CJ
Relationship to deceased
Name of Funeral Hom'zzz:2�
IMPORTANT
I represent that to the best of my knowledge, the decease 11as 'r has 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 ally 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 cfenialloit of said remains as directed,whether
such claims or de nds are or are not wholly groundless, false or fraudulent.
( S) (ADDR )
(SIGNATURE OF REI.ATI R LEGAL RV-.. AND ADDt�E )
. /
Signed on this dale: �Q