Kimball, Robert rl-O q+N OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12904
(518) 745-4476 (518) 745-4477
Funeral Director 5�`r/�/�� �.�/U l,E
Name Old�� f4 rJ/Ael ,�"k Case # Z j
Date of Cremation Z ) 7 — L
Time Cremation Started
Time Cremation Completed
Type of ContainerC44l* )3 dL1kr 2 AAq
Remarks :
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TOWN 01: QUEE14SBUIlY 3? 3
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury. New York 12UU4 '
Phone t518) Cren►alorium 745-4477 (il no answer)
Cemetery 745-4470
AU-I-1-10121ZA'I ION 'I U UREMA I E
The undersigned requests and authuiizes fine View l IUMalUHL1111. in accuidance with and subject
to its Rules and Regulations to cremate.the iernains ul:
(NAME) (SEX)
(STREET) Z7 (CITY) (S fA l E) (ZIP CODE)
who died on ) day or K?ua �>f 20—LL9—
at
(PLACE) (ADUTAESS)
Name and address of nearest living relative or name of person authorizing cremation:
Relationship to deceased LU C•.
Name of Funeral Home
IMPORTANT
I represent that to the best of my knowledge, the deceased has Iras r10 acernaker In his or her
body. (CIRCLE ONE)
I certify that I have the full power and aulhorizatioti to arratlye for the creiation 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 darnages which may be made
against I"reason of or connected with the cremation of said remains as directed,whether
uch ci ms or im nds Wy or are not wholly groundless, false or fraudulent.
�Os
(WIT SS (A ESS)
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(::��
(SIGNATUR OF R LATIVE OR LEGAL REP. AN ADDRESS)
Signed on this dale:
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