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Subers, Virginia TOrWN OF QUEEN,5BU—r� PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director i,'t,l&kV--fie-fl A4e—, t� a^ e 1/. T2'G L14VP" SU Casea �3 Ere 01 Cremation Cremation Started 're Cremation Completed o e of Con t a i n e r_C,&'-)-r) 12rj� ;_—arks i llQ)��T.n 1 1 a�i2 nt i l'OWN 01: QUEE14SUUIIY PINE VIEW CEME*I EIIY ' 3. CREMATORIUM Quaker Road. Oueensbury. New York 1213U4 Phone (51©) Creiviatorium 7.15-•1477 (il no answer) Cemetery 7,15-4476 AU1'I-IOIZIZA•I ION 'I U GREMA i E The undersiyned requests and authuiizes fine View 0 ell atui it"ir. in accuidance with and subject to its Rules and Reyulations to cremate,the iemsioss ul. (N E) (SEX) 71Y4 2-1 (STREET) (CITY) (SIAI -) (ZIP CODE) who died on t'w day ul A!2eeA7rAz6120� at (PLACE) DDRESS) Name and address of nearest living relative or lrarne of person authorizing cremation: Relationship to deceasedT � / Name of Funeral Home ' _ IMPORTANT I represent that to the best of my knowledge, the deceased has 1as 11 acemaker In his or her body. (CIRCLE ONE) I certify that I have the full power and authorization to arrallye for [lie 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 cterrlallorl of said remains as directed,whether such claims o-1-0- r de ands are or are not wholly groundless, false or fraudulent. ( I -/-- ��Z 7 ESS) (ADDRESS 1� lu.Ua"" W , wUK.Jy - Z--1 1.1 _tz_vtn (SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS) Signed on this dale: /oZ 17/off