Pratt, Arthur TOWN OF Q UEENS B UR Y
Pine Virtu Centetery mid Crentntorturn
21 Qunker Rond, Queensbury, NY. 12804-5902
(518) 745.4476 (518) 745•4477
http //w%v\v queensbury net
Funeral Director:
Name of Deceased:
Case Number:
Date of Cremation: oZ - l (� Z C C) J�
Retort: AVJ%d --Z- w
Time Cremation Started:
Time Cremation Completed: G
Type of Container: �� �o G ,/�Vl ►�-i oZ ��I��l
Remarks:
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Hone of Nnturnt Benuty ... A Good Plnie to Live
TOWN OF QUEENSBURY r
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or 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:
(Name) (Sex)
(Street) (City) ( e) (Zip Code)
who died on �� . "� day of M or ! - ��>
at (o1Qn5l7rkll y0piL4 /00 Park s4 - o Ien l( g_ 1ti'�f
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
(Name) (Address)
Relationship to the deceased LI) e-QQ -G
Name of Funeral Home A0,4 jrU nd �, la4-l�K 6Vux-^' �
��
IMPORTANT:
I re r se t to the best of my knowledge, the deceased has or
has <o acemake� 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.
4,zip-el atdi7L-e 1 10-10 i,lesf '04-
y�li ness) (Address)
(Signature of Relative or Legal Rep. and Address)
Signed on this date: PeIL LV