Clark, Randon TOWN OF QUEENSBURY
Pine View Cemetery nnrl Cremn tort um
21 Qunker Rond. Queenshury, NY. 12804.5902
(518) 745.4476 (518) 745.4477
http//w\v\v queensbury net
Funeral Director: AS /►-Lrj C"2,-V
Name of Deceased: �R r*l� /V\ G f�,LA.Q-1-
Case Number: W
Date of Cremation: } 3 -- t '""� �— do
Retort:
Time Cremation Started: 1G1-
Time Cremation Completed: ) ' (� `j 14 ^'L
Type of Container:
Remarks:
Home of Nnturnl Benuty . . A Good PInie to Live '
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
8
CREMATORIUM
Quaker Road. Queensbury, New York 12804
Phone (518) Crematorium 7454477 (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: m
k , A
(NAME) (SEX)
v
(STREE 1 (CITY) (STATE) (ZIP CODE)
who died on 5 day of 20 65
(PLACE) 0 (ADDRESS)
Name and address of nearest living relative or name of
C person authorizing crema tion
/ ir 6. A,
el— e •�Lr✓ 4A"C,
Relationship to deceased
Name of Funeral Home nSMor e rY t ,ra 1
IMPORTANT
I represent that to the best of my knowledge, the deceased has pr has no a 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 errands are or are not wholly groundless, false or fraudulent.
'(WITNESS) (ADDRE
CS Q•-rt--Q
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: 3 / l ) / OS—