Cooney, Claire TOWN of QUEE� ODU
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12904
(518) 745-4476 (518) 745.4.477
Funeral Director jjtjc'kr-�- - yt'-P�`'k
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TOWN 01: QUEENSUUI2Y '5 r J
PINE VIEW CEME'VERY `
CIIEMA'I'OIZIUM
Quaker Road. Queensbuiy. New Yoik 12UU4
Phone (518) Crei»aloiium 745-•1477 (it no answer)
Ceineteiy 745-4470
AU1'1-IOIIIZA'I'ION 'I O C REMA i E
The undersigned requests and aulhwizes mine View in accuidance with and subject
to its Rules and Regulations to ciemale_the remains ul:
^ 1F1iYC 6t' Y1
(NAME) d (SLX)
`-)3
(STREET) (CITY) (SIAIE) (ZIP CODE)
who died on 2 7 day of
at L-1 1t�.
(PLACE) (ADDRESS)
Name and address of nearest living relative or naine of person authorizing cremation:
C 17c `T
Relationship to deceased S�
Name of Funeral Home
IMPORTANT
1 represent that to the best of my knowledge, the deceased has or Itas Ito acemaker In his or her
body. (CIRCLE ONE)
I certify that I have the full power and aulliorizatiort to arrange for [lie 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 f or connected with the cteinalion of said remains as directed,whether
such claims or dema s re or are not wholly groundless, false or fraudulent.
(WIT SS) (ADDRESS)
ZA
(SIGNATURE OF TIVE OR LEGAL REP. AND ADDRESS)
Sig d on this date: 7r
x
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