Dalaba, Marjorie rrO UN OF QUEEVBU�Ky
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name �Mq dati 1_, L D1j*L Case #
Date of Cremation
Time Cremation Started —1L-1
Time Cremation Completed
Type of Container G ��s /►�L�4Nd
Remarks :
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TOWN OF QUEENSBURY ���
PINE-VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensoury, New York 12804
Phone (518) Crematorium 745-4477 (if no answer)
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium. in accordance with and sub)ect
to its Rules and Regulations to cremate the remains of:
7LC
(N ME) ^^KID
(SEX)
(STREET) (CITY) (STATE)
(ZIP CODE)
who died on `�
day of
at f�a(
(PLACE) ti�c
(ADDR SS)
Name and address of nearest living relative or name of person authorizing cremation:
I a
Relationship to deceased
Name of Funeral Home
IMPORTANT
I represent that to the best of my knowledge, the deceased has r has no pacemaker 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 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 demands are or are not wholly groundless, false or fraudulent.
( ITNESS) ) (A ESS)
Aj
(SIGNATU OF R LATIVE OR L GAL REP NA ADDRrE{S5,�
Signed on this date: g�S� O �-