Hayes, Wilma TOrWN OF QUEEN5O UT.
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745.4.477
//,, Funeral Director �� C- -a4w � C-w4) L1
`a-e YI1 OA C/ 1414 ��� Case# a
to
,.are Of Crema t i.on �'„Z _ Z _ Z-O0
Cremation Started /A,
_'re Cremation Completed
e o I C o n t a i n e r Ci64N?� AL[��
�eT,arks
cl 570 G4�
/G , o ior�
lv � �
i
TOWN OF QUEENSBURY
PINE VIEW CEMETERY&CREMATORIUM
Quaker Road, Queensbury, New York, 12804
Phone (518) Crematorium 745-4477 of no answer Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in Accordance with and subject to its
Rules and Regulations to Cremate the remains of:
Name ^ (Sex)
\
3,6 ,,L., A-C any P0�r.s
fY77 c", ,,r s z A-i P
(Street) (City) State) (zip)
who died on d day of ice:< 1 20 09
at _ _ ) ZG-14 r, 0<<h-h C-1 drIJ us^s �r�•
(Place) (Address)
Name and address of nearest relative or name of person Authorizing cremation:
(Name) (Address)
Relationship to the deceased
Name of Funeral Home ii7
IMPORTANT:
I represent that to the best of my knowledge, the deceased has o has n Opacemaker 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 such claims or demands are or are not
wholly groundle s, false or fraudulent.
(Witness)' ddress)
(Signatur of Relative or Legal Rep. a Address))
Signed on this date:
X