Schwarz, Beryl OF QUEENB U Py
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director L5;oC•,,-j-i�+tG N tA eliA It L-
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Cremation Started
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, e Cremation Completed
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TOWN 01: QUEE14SUUIIY
PINE VIEW CEMETERY ;
CREMATORIUM
Quaker Road. Queeiisbuiy. New York 1213U4
Phone l510) Crematorium 745-4477 (it no answer)
Cemetery 745-4476
AU'1'1-10131ZA'I ION 'I U CREMA I E
The undersiyned requests and authorizes fine Vi0W CIU111atoiRnii. in accuidance with and subject
to its Rules at d Regulations to cremate,the iemains ul:
z
(STREET) (CI-IY) J I(S'IA'IE) (ZIP CODE)
who died on /> day of
at L
1 l�
(PLACE) (ADDRL=SS)
Name and dress of n arest living relative or name of person authorizing cremation:
Relationship to deceased
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Name of Funeral Home v n — �1 C C�
IMPORTANT
I represent that to the best of my knowledge, (he deceased has or I as n pacemaker 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
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 crernalion of said remains as directed,whether
such claims or demands are or are not wholly groundless, false or fraudulent.
ITNES (ADDRESS)
(SIGNATURE ELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: