Murray, ALice TURN OF QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director S,11 II
Name VC( Ctt, Case #
Date of Cremation ([— q , y1
Time Cremation Started I) ' 5-0 AM -
Time Cremation Completed
Type of Container CA4 04It CC ret Cg�e
Remarks :
� ' Io P.rt=S � PM
TOWN O1= QUEENSI-WHY
PINE VIEW CEMETERY •
CREMATORIUM
Quaker Road. Queensbuiy. New York 120U4
Phone (518) Crematorium 745-4477 (if nu answer)
Cemetery 745-4470
AUI I-IOIZIZA'I ION 10 GREMA I E
The undersigned requests and authorizes fine View Cie-matuimin. in accuidance with and subject
to its Rules and Regulations to cremate.the remains ul:
(NAME) (SEA)
clq-7 671 s i7Aws Ny t >1 o
(STREET) (CITY) ' t (SA l L) (ZIP CODE)
who died on day of IyoVewr her" zo d y
al ;/ fzl< 6T, lP�evtS
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
cS h Q V L!j I,t4YVI 6
Relationship to deceased 11-U�
dmt�-Name of Funeral Home � e3W"Md) lkly�
IMPORTANT
I represent that to the best of my knowledge, the deceased has or has 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 darnages which may be made
against them by reason of or connected will) the crelnalion of said remains as directed,whether
suc aims or de ds are o not wholly groundless, false or fraudulent.
t
(WITNEYJ
) (ADDRESS)
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this dale: 11L16 1 10