Guy, James Sr. TOWN OF QUEENSBURY
Pint Virtu Cemelery and Cremn tart tt/it
21 Qunker Rond, Queenshury, NY. 12804.5902
(518) 7a5.4476 (518) 745.4477
hitp/lw\v\v queensbury net
Funeral Director:
Name of Deceased: Y-lM � U �i
Case Number: ed
Date of Cremation:
Retort:(),a41/0 E01 Z d
Time Cremation Started: S 5 to(
Time Cremation Completed: �-
Type of Container: � �
Co
Remarks:
" Homy o/ NntitrnI Benu A Conti PInie In Live
TOWN OF QUEENSBURY
PINE VIEW CEMETERY&CREMATORIUM
Quaker Road, Queensbury, New York, 12804
Phone (518)Crematorium 745-4477 of 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:
�n_vrne-.r m. C,3„ Sr .
(Name) (Sex)
j 4 �_. K 1l. Xy
(Street) (City) (State) (zip)
who died on g day ofr,�� 20 QS'
at
(Place) (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 r has no acemaker in i
(Circle One)
I certify that I have the full power and authorization to arrange For the cremation of this :*I
direct the disposition of the cremated remains, that any personal possessions have either t
or may be destroyed, and agree to protect, defend and save harmless Pine View Cremato,
and ail claims and demands for loss or damages which may be made against them by
connected with the cremation of said remains as directed, whether such claims or demands
wholly groundless, false or fraudulent.
= _J A_"� _', -4
dr ss)
( ignature of Relative or Legal Rep. and Address))
Signe te: '� 6s