Johnson, Art rl-o`KN OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director����,� T �ehriN
Name Case # "J j V
Date of Cremation
Time Cremation Started `� . 'J Lj /� , M.
Time Cremation Completed t
( �Z;G U p
Type of Container Cotr-A%;ar � L , r �1� C`,qLQ
Remarks :
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TOWN OF QUEENS,5IL RY I
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:
�A ri 5 0 2 11-c ,
(Name) (Sex)
(Street) (City) (State) (zip)
who died on ) day of >y C1 L 20 L7 y
at C)I1. u. I), )-�c �Q
(Place) (Add ss)
Name and l)address of nearest relative or name of person Authorizing cremation:
�iV- c0-1 UP)a7!®cyra
, n
(Name) ( ress)
q
Relationship to the deceased
Name of Funeral Home
IMPORTANT:
I represent that to the best of my knowledge, the deceased has o has no pacemaker in his or her!'ndy.
(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 ar,y
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 groundless, false or fraudulent.
X%—J'R-
(Address)
(Signature of RAfiv6tr Legal Rep. and Address))
Signed on this date: