Schaap, Andrew rroTVN of QUEENSBWhy
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director /y� ��T �,� '
Name ' T� EW � ��1� R� Case # �j
Date of Cremation Z0C/
Time Cremation Started r~1 S 14
Time Cremation Completed � tJ'
Type of Container(r, ��v /►�#41
Remarks :
�
S���'�-'c'l
TOWN OF go-
PINE VIBN C8lIR'1'SRY
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
At�3'RORIZATIOR TO CRBKATS'
The undersigned requests and authorizes Pine View Crematoriums in
accordance with and subject to its Rules and Regulations to cremate
the remains of:
(Name) (Sex)
YL �?e,!;—
(Street) (City) (State) —'(ZiCode)
who died on day of rerti�c�
Q�� r
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
_ e f2-.rw 21-
(Name) I (Address)
Relationship to the deceased
Name of Funeral Home (new -�
IIfPORTA�iT
re resent that to the best of my knowledge, the deceased has or
as 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 such claims or demands are or are not wholly
groundless, false or fraudulent.
(witness) —'�° (Address)CTY
gva
(Signature o at ve or Legal Rep. and Address)
Signed on this date: N-0 . 17 y