Tedesco, John C:) TOWN OF QUEENSBURY
Pine Virtu Cemetery nnrl Crentn tort um
27 Qunker Rood, Queenshury, NY. 72804.5902
(518) 745.4476 (518) 745.4477
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Funeral Director: ��-►�cia �� �`l 1�1
Name of Deceased: — N -TE�) 1 S C)
Case Number: 5 2
Date of Cremation: �- _ Z C)d 5
Retort: �
Time Cremation Started: M
Time Cremation Completed:
Type of Container: C'�V2—a �U✓-��Z[J /� � ��� 10
Remarks:
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Home of Nntttrnl Benuty ... A Good Plnie to Live
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY&CREMATORIUM
• Quaker Road, Queensbury, New York, 12804
Phone(518)Crematorium 745-4477 of no answer Cemetery 7454476
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:
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(Name) (Sex)
(Street) (City) '(State) (Zip)
who died on o day of C"C o rltAO 20 6`Y
at �s� eves .t(s
(Place) I (Address)
Name and address of nearest relative or name of person Authorizing cremation:
(Name) (Address)
Relationship to the deceased (--
Name of Funeral Home
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 damages which may be made against them by reason of or
,onnected with the cremation of said remains as directed, whether such claims or demands are or are not
"v groundless, false or fraudulent.
(Address)
'e or Legal Rep. and Address))