Higgins, Ernes "'o WN OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director /V1 , 13 IL
Name Jif\( Ca 0 17-1 Case # L.1 i-1 \
Date of Cremation� oU CA
Time Cremation Started
Time Cremation Completed
Type of Container AA
Remarks :
A/ � 1
TOWN AMM9MMY
PINX VIZK CZK9MT
i
C TORIlam
Quaker Road, Queensbuxy, Now York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
ALITSORISATICK TO
The undersigned requests and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to cremate
the remains of: JZ
(Name) (SOX)
(Street) (City) T (State) (Zip Code) '-
who died on _ day of �, L91
at G '-) s ri w d Z_ f�
(P ace) (Address)
Name and address of nearest living relative or name of person
a horizing crema ion:
(Name) (Address)
Relationship to the deceased tA I /F .�
r
Name of Funeral Home
IltPOItTANT:
I represent that to the best of my knowledge, the deceaseei ha or
rhe acemaker in his or her body. (Circle One)
J _?z�,w
I certify that I have the full power and authorization td-arrange
for the cremation of the ruins 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, f�lse r fraudulent.
.� Gr
s
(W ess) (Ad ems)
r �
OC
(Signature of Re tive or Legal Rep. and Address)
Signed on this date: iC9 �otj