Kelly, Bernard rrn'WN OF Q,Z.IEE 5BUT�y
PINE VIEW CEMETER'1 AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12904
(5 18) 745-4476 (518) 745.4477
Funeral Director
a-e C a s e Wr
�F Cremation
5-
Cremation Started 16
e Cremation Completed
e of ContainercLZ-)-") 130,1(-20 6 At
A4;6,- f""I
a r k S
A--
o
�7
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 Regulations to cremate the remains of:
� f
(NAME) (SEX)
(STREET) (CITY) (STATE) (ZIP CODE)
who died on day of 6, 20 y 5-
at 140
(PLACE) (ADDRESS)
r'
Name and address of nearestliving relative or name of person authorizing cremation:
K5-i
�1
Relationship to deceased_
Name of Funeral Ho , • • �` �� /
IMPORTANT �as
—I represent that to the best of my knowledge, the deceased has o4o pacemake 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.
d -,
L WITNES ) (ADDRE S)
(SIGNATURE OF FfELATIVEZR LEGAL REP. AND ADDRESS)
Signed on this date: