Celeste, Gerald Sr. rl-O q+N OF QUEEVBU�KY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director j ^-, 'tom
a s e # t. L( n
Date of Cremation J �(� — Z -"o 4
Time Cremation Started 'q O 14 -lam
Time Cremation Completed `
Type of Container d oo
Remarks :
in 77 1'-41
1�--�, 5 Pam,
A41
I
TOWN 01: UUEENSUURY
PINE VIEW CEMETERY
& ,
CREMATORIUM
Quaker Road. Queensbury. New Yuik IZUU4
Phone 1518) Crernalodum 745-4477 (if no answer)
Cemelery 745-4476
AUTHORIZA"I ION '1 0 C REMA l E
The undersigned requests and autimizes fine ViUW UelIMIUM1111. in accuidance with and subject
to its uses and Regulatiioo'ns to cieniale•the ieniains ul.
(NAME) (SEX)
l� 5 10o C) tfk i
(STREET) (CI•IY) (51 'I E) (ZIP CODE)
who died on day of �V 20at 0(e*,�
(PLACE) (ADDRESS)
Name nd address of nearest living relative or name of person authorizing cremation,
z. � crt
0
Relationship to deceased y S'
Name of Funeral Hom )U--ul I ' 't—` � � 4 G �
IMPORTANT
1 represent that to the best of my knowledge, (lie deceased has or lias ri pacemaker In his or her ,
body. (CIRCLE ONE)
1 certify that I have the full power and authorization to arranye 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 crerliation of said remains as directed,whether
such claims or d mands are or are not wholly groundless, false or fraudulent.
Cam. �
(WITNESS) (ADDRESS)
(SIGNATURE OF RELATIVE OR GAL REP. AND ADDRESS)
Signed on this date: Nv. I� Zo"'X+