Nasholds, Lillian rrO rMN OF QUEEVBU—r�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 5 ,jj _ �,n4Las,
Name L I V'5► 0ij5 Case # 1-na
Date of Cremation IU -- k$ —bq
Time Cremation Started
Time Cremation Completed I U L M
Type of Container C,grctbogr� rhwferd /Sf cis0 Cf- G 5�
Remarks :
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a
I U
TOWN 01: QUEE14SOU11Y I ,�
PINE VIEW CEMETERY l�(
3.
CREMATORIUM
Quaker Road. Queeiisbuiy. New Yolk 120U4
Phone (510) CremaluHum 745-4477 (if nu answer)
Cenielery 745-4476
AU'1 I IOIZIZA'1 ION 'I U UREMA I L=
The undersigned requests and authorizes I-Iiiie View Giemaluiiuin. in acculdance with and subject
to its Rules and Regulations to ciemale.the oemains ul.
(NAME) (SL=X)
9
(STREET) (CITY) (S I AYE) (ZIP CODE)
who died on day uI ��� 200rgA
(PLACE) (ADDRESS)
Name nd address of nearest living relative or name of person authorizing cremation:
Relationship to deceased
Name of Funeral Home w
IMPORTANT
I represent that to the best of my knowledge, the deceased has 11as 110 acernaker In 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
ze Z2�-
Crematorium from any and all claims and demands for loss or darnages which may be made
against them by reason of or connected with the cremation of said remains as directed,whether
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laims or Amands are or are not wholly groundless, false or fraudulent.
WITNE ) D SS)
(S GNATURE OF RELATivit OR - AND ADDRESS)
Signed on this date: