Vaughn, Donald a
TOWN OF QUEENSBURY
Pint Vtett, Cemetery nod CreinntorlUlll
21 Qtnker Ronri, Qiteenshnry, NY. 12804.5902
(518) 74 5.44 76 (518) 745.4477
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Funeral Director: r
Name of Deceased: Vvha I d Gvq 4 h
Case Number: 1615
Date of Cremation:
Retort: Cr fora
Time Cremation Started: �° 60 A
Time Cremation Completed: i u � o A
Type of Container: ( A r o g,rcI
Remarks:
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TOWN OF QUEENSBURY D ��
' PIKE VIEW CEMES'ERY
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:
IAI
(Name) q (Sex)
AY I Le y J—
(Street) (City) (State'�ip Code)
who died on �3 day of l QED S�
a C A-a4C (; T _ �
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
S:�p J-9 t Ja
(Name) (Address)
Relationship to the deceased
Name of Funeral Home &g,��Tc��[� /tG�
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 connected with the cremation of said remains as
directed, whether such claims or demands are or are not wholly
groundless, false or fraudulent.
Lr
z
(Witness) (Addre s)
(Signature of Relative oregal Rep. and Address)
Signed on this date:
I