Robinson, Helen TOWN OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name Case #
Date of Cremation (Q — 2- '.7—
Time Cremation Started �� -
Time Cremation Completed
Type of Container, \-2\
Remarks :
. 1 ('.41
TOWN OF OUEENSUUIIY '
PINE VIEW CEMETERY
CREMATORIUM`
Quaker Road. Oueeiisbuiy. New Ypik 120U4
Phone (610) Creniatuiium 7,15-•1477 (i1 nu answer)
Ceineteiy 740-447U
AUTI•IORIZA l ION '1 U GREMA I E
The undersigned requests and authuiizes Dille ViUw laeniatunuin. in accuidance with and subject
to its Rules and Regulation to c1e le the remains ui:
(NAME)
(STREET) ( (S4 A =) (ZIP CODE)
who died on f day ul 20
at
(PLACE) AADURESS)
Name and address of nearest living relative or name of person authorizing cremation:
Relationship to deceased
ZlevName of Funeral Home
IMPORTANT
I represent that to the best of my knowledge, the deceased has u 1as Ito acemaker in his or her
body. (CIRCLE ONE)
1 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 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
such claims or demand re or are(not wholly groundless, [also or fraudulent.
22-
(WITN S T 7- ,,�(AD ES )
(SIG TURE F RE IVE OR LEGAL REP. AND ADDRESS)
Signed on this d
„ M 17
a�{Y
N . 42%NYC
019) f 2{pI
"Customer's Designation of Intentions”
Name of Deceased.: ` T,.w,.C.t. V-?
Cremation" /'�,,l .Z 2/d
(Scheduled Date)
(Location)
Manner of Disposition of Cremated. Remains:
❑ Burial at Return to Family
❑ Entombment at ❑ Other (specify):
I hereby designate the Di 'ositi n of Cremated.Remains and ackngwledge receipt of a copy of
tins form. (Sel
igna e) r' /
�( Tinted Name) (Relationship to Deceased)
s
'Add
(Telephone Number)
"Cremated. Remains which shall not have been claimed. within 120 days from the date of
cremation may be disposed of by this firm by plagement in a columbarium."
Printed Name of Funeral Director S' nature of Funeral Director Date
or Undertaker or Undertaker
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS
Cremation:
(Actual Date) (Location of Crematory)
Disposition of Cremated Remains:
(Manner of Disposition)
(Location)
(Date)
Name of Person Making Disposition Signature Date
#9 " WHITE:Funeral Home Copy YELLOW:Family Copy. PINK:Crematory Copy CUSINTEN Rev.4/96