Berry, Steven C:) -.A TOWN OF QUEENSBURY
Pine View Cemetery mid Crernn tort utit
21 Qunker Rond, Queenshtrry, NY. 12804.5902
IIjW (518) 745•4476 (518) 745•4477
htrp/iw%v\v queensbury.net
Funeral Director: c ,
Name of Deceased: t.' C, 3 I% I z
Case Number: J
Date of Cremation:
Retort: T r E
Time Cremation Started:
Time Cremation Completed: ® ��-
Type of Container. /Vt y�1 11 AL
Remarks:
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" Home of Nntttrnl Benttty ... A Good Plnie to Live "
TOWN OF QUEENSBURY
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)
/� AwL f /,—, e-e2e
(Street) (City) (State) (Zip Code)
who died on 2 5 +41 day of Ma.rU Qck-��-
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(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
_�Q 1ro-� CdWar�
Z 2rfo rt/Y !Z
(Na (Address)
Relationship to the deceased
IJ
Name of Funeral Home --Galata n Fmebra! Hem ine
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or as n
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 connected with the cremation of said remains as directed,
whether such claims or demands are not wholly groundless, false or fraudulent.
R /
�. IPu y 1432
(Wit s) (Address)
( ig ature of Relative or L al Rep. and Address)
Signed on this date: 3L26 0)