Boisvert, Judith LO Y N OF QUEEVBU9�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name ^S.0c ti A- K )A, & S i/eV i Case #Date of of Cremation � � — ►� — 'LG�o�LI
Time Cremation Started (j .✓V�
Time Cremation Completed
Type of Container /h V;, �0 .-4-t
Remarks :
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TOWN OF QUEENSBURY �^
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 (if 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 Regulia2tions to cremate the remains of:
(NAME) (SEX)
(STREET) (CITY) (STATE) (ZIP CODE)
who died on ;fa � day of /J v V C—', e r 20 O `t
at ,(�^'lay(/C '!�i — �� ,�^� /`� f 1'L ..e il./V rt,� Clef /t> l
(PLACE) (ADDR S)
Name and address of nearest living relative or name of person authorizing cremation: y
__mac JAB
7 L
Relationship to deceased S4) s'
r _
Name of Funeral Home
IMPORTANT _
I represent that to the best of my knowledge; the deceased has Fl-has no pace am k r 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 groundless, false or fraudulent.
�iy K r ens.. 1< r:c % /a)
12
WITNE lil (ADDRESS)
t �'
(SIGNATURE OF RELATIVE OR tEGAL REP. AND ADDRE S)
- o 0 Signed on this date.