Lockwood, George . .L-%-/ 1 IUEEN,5BURY
PINE Vll- ?', '-' AND CREMATORIUM
QUA.CER J „,BURY, NEW YORK 12804
(518) 745-4477
rector
Name &90R&-e cm 1,o c t<wc ease #
Date of Crematioii
Time Cremation S-:art. 1 '-q �� AP
Time Cremation C ,mr_ _
Type of Containe --cj�
Remarks :
_ _ , c �
TOWN OF OUEENSUURY r2 -7
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road. Queensbury. New York 12UU4
Phone 1510) Crematorium 745-4477 (it no answer)
Cemetery 74G-4476
AUl•I"10121ZA'I ION "I U C REMA l E
The undersigned requests and aulhurizes fine View GienralunUnn. in accuidance will) and subject
to its Rules and Regulations to cremate.the remains ut:
LINAME) (SEX)
all I
(STREET (CITY) (S"1A1 =) (ZIP CODE)
who died on f day of 20
at g
(PLACE) (ADURL=SS)
Name and address of nearest living relative or name of person authorizing cremation:
Relationship to deceased
Name of Funeral Home Z -
IMPORTANT
1 represent that to the best of my knowledge, the deceased has or 1as r10 acernaker In his or her
body. (CIRCLE ONE)
I certify that i have the full power and authorization to arrange for (lie 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 crernation of said remains as directed,whether
such claims or demand are or are not wholly groundless, false or fraudulent.
( TN SS) (ADDRESS)
L�G
SIGNATU E OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: