Skinner, Carol TOWN OF QUEENSB21-r�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
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TOWN OF OUEE14SUUIIY
PINE VIEW CEMETERY ) t
CREMATORIUM
Quaker Road. Queeiisbuiy. New Yuik 120U4
Phone t510) Creinaloiium 745--1477 (i( nu answer)
Cemetery 745-4470
AU-I'I-IORIZA'I ION 'I U (;IZEMA I E
The undersigned requests and authuiizes Dine View Uiemalunum. in accuidance with and subject
to its Rules and Regulations to cremate-the ieniahis ul:
aye o� � �rr� z_ f cim0c�
(NAME) (SEX)
( 7 (Mi4L) 1-4,>J ST- erzp" L263Z
(STREET) (CITY) (SIAIE) (ZIP CODE)
who died on 24 day ul 20 d4
at r .,:, -X1,1rs4 b n-e— IM�66600
(PLACE) (ADDRESS) �—
Name and address of nearest living relative or name of person authorizing cremation:
lZ? bl
Relationship to deceased
Name of Funeral Home� �J+�rJ �Ul tnuha*v 1 22�
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 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 cremation of said remains as directed,whether
suc cl s or deman s a or are not groundless, false or fraudulent.
(WITNE DDRESS)
'qfGRAfURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this dale: D 4