Kelly, Barbara rrocW N OF QUEENBU-�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Dire ctortilil,:,kErc, N gkE:j4A c�
Name '319 'Q J's" - .ti �, Case #
Date of Cremation -7 L —t—cc- 1
Time Cremation Started Q , ) Q 4A--41
Time Cremation Completed
Type of Container G -)-,Ik�9AA-.-2,J ' ,77 }�•
Remarks :
i
TOWN 01= QUEENSBURY
PINE VIEW CEMETERY '
CREMATORIUM
Quaker Road. QueerrsUury. New York 12004
Phone 15113) Crenialoiium 745-4477 (if no answer)
Cerrrr?lery 745-4476
AU'TI-IOHIZATION l U CREMA I E
The undersigned requests and authorizes fine View GlerrlalurlUll). in accordance with and subject
to its-Rules and Regulations to cremate-the remains ul:
bye-
(NAME) (SL=X)
(STREET) (CI-IY) ( TAIE) (ZIP CODE)
who died on C7LJ day of Safi 20
at SOS CM 1_
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
1 Y)C'f(, der ma S
a
Relationship to deceased l Tic
Name of Funeral Home
IMPORTANT
I represent that to the best of my knowledge, the deceased has Ifas ff pacemaker In his or her
body. (CIRCLE ONE)
I certify that I have the full power and aulltorizaliolf to arrailye for life 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 t0 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 dema!pds are or are not wholly groundless, false or fraudulent.
(WI E S) (ADDRESS)
a,VJ
(SIGNATURE F RELATIVE G5R LEGAL REF'. AND ADDRESS)
Signed on this date: �\ ,�®