Wood, Charles �o OF QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director J (, ool �'( u—
Name Clk n r I e ,; U,r 0 Case # L/ - '
-
Date of Cremation..
Time Cremation Started DO
Time Cremation Completed � � A-) I
r
Type of Container C a 11� C?�
Remarks : Z ��
rn 2 11-e—
i 9
fill
i
i
i
i
i
TOWN OF OUEENSUURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road. Oueeiisbuiy, New York 12UU4
Phone t51U) Creniatoiiunr 745-4477 (it no answer)
Cemateiy 745-4476
AUTHORIZATION l O CREMA I E
The undersigned requests and autho0zes fine View GIU111a(WIL1111. in accuidaiwe with and subject
to its Rules and Regulations to ciernale,the remains ul:
( YI Qhh'4) 6. &Jon I / I _C
(NAME) (SLX)
>9 /Jo z . /ddz
(STREET) (CITY) V
) IS I A i L) (ZIP CODE)
who died on clay of 20,04
at W'oz-'�LA ) 1�02(
(PLACE) (ADURL=SS)
Name and address of nearest living relative or narlle of person authorizing cremation:
Qe0kC?10_ zeo-ko's- 000<-
Relationship to deceased Z"or
Name of Funeral Hom n z /IYn Q_
IMPORTANT
I represent that to the best of my knowledge, the deceased has or has no pacemaker In his or her
body. (CIRCLE ONE)
I certify that I have the full power and authorization to arranye 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 connec itil the cremation of said remains as directed,whether
such claims or demands are or are t wh fly groundless, false or fraudulent.
(WITNESS) (ADDRESS)
-SC ♦ I 19 NBea
(SIG ATUR OF ELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date:. 16ZzLog-