Casey, Richard rrnTVN OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director rj J ��,� ii
Name +e14 -A7 r' C 14Se Case # -2- 76
Date of Cremation
Time Cremation Started_�f(�
Time Cremation Completed N]
Type of Container (*
Remarks :
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TOWN OF OUE-ENSUUIIY •
PINE VIEW CEMETERY
& '
CREMATORIUM
Quaker Road, Oueensbuiy, New Yolk 120U4
Phone t510) Creinoloiium 7,15-•1477 (il nu answer)
Ceineteiy 745-4470
AU•1'I IU121LA'I ION •1 U UlIt_MA I L
The undersigned requests and aulhwizes Dille Viuw l;iLlllatu1111111. in acculdarrce with and subject
to its Rules and Regulations to ceemate the iemahrs ul:
(NAME) (SLX)
333 2; o tou,� uc /s,3t.,re
(CI IY) (S I A I I:)) (ZIP CODE)
(STREET)
who died on C:'� clay of V�(/✓C 20
(PLACE) (ADDRESS) l
Name and address of nearest living r live or name of Person authorizing cremation:
Relationship to deceased 101
Name of Funeral Home n Q 6
IMPORTANT
I represent that to the best of my knowledge, the deceased has or 11 s Ito acemaker In his or her
body. (CIRCLE ONE) '
I certify that I have the full power and authorization to arrallye for the cremation of the remains and
to direct the disposition of the cremated rernains, 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
suc claims or demands are or a not wholly groundless, false or fraudulent.
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(WITNES (ADDRESS)
CZ- ,12-Z) A,
(SIGNATURE OF RELATIVE OR LEGAL REP. ANU ADDRESS)
Signed on this date:_ •f�L k