Mosier, Philip OF QUEEVBU9 y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name ��.xl-i e A400i Case #
Date of Cremation Za — < — `Z 0,51-t
Time Cremation Started N�
Time Cremation Completed 3
Type of Container
Remarks :
�P41
i
1'OWN 01= OUEENSUURY
PINE VIEW CEMETERY 1
CREMATORIUM
Quaker Road, Queensbury. New Yuik 12UU4
Phone 15la) Crenialodum 7,15-4477 (if no answer)
Cemeleiy 745-447G
AU'I'I IOIZIZA I ION 'I U GREMA l E
The undersigned requests and authorizes I-Iine View Cienmalununr. in accuidairce with and subject
to its Rules and Regulations to cremate,the remains ul.
(NAM ) (SEX)
(STREET) (CI-IY) (S1 A 1 U) (ZIP CODE)
�j--�A
who died on I day of
(�-� 20 d
ate^+',}
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Relationship to deceased—
Name of Funeral Home
IMPORTANT
I represent that to the best of my knowledge, the deceased has It lto acemaker In his or her
body. (CIRCLE ONE)
I certify that I have the full power and aulhorizalion to arranye for lite 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 retrains as directed,whether
such claims or demands are or are not wholly groundless, false or fraudulent.
WITNESS) (ADDRESS)
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: