Flammer, Andrea f TOWN OF QUEENSBURY
Putr Vtrto Cemetery nrtA Cremn tort utit
21 Qtrnker Rond. Queenshury, NY. 12804.5902
(518) 745.4476 (518) 745.4477
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Funeral Director: 13 r-iKr4"
Name of Deceased: vn w r
Case Number: a G a
Date of Cremation:
Retort: CrCI t4)F, rd
Time Cremation Started:
Time Cremation Completed: Z y 5
Type of Container: A rci �j c G r c9
Remarks:
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TOM OF QU--- 5DURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHORISATION 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)
2 7 I L U 2-O
(Street) (City) (St e) (Zip Code)
who died on O day of IqV I--2�S---
at CiiEA qi/)s Pt 7- 5-. t
(Place) (Address)
Name and address of nearest living relative or name of person /
authorizing cremation:
10
(Name) (Address)
Relationship to the deceased Sv^�
Name of Funeral Home I& / 7
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 toyarrange
for the cremation of the remains and to direct the disposition of
the cremated remsa i ns, 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
groundles ;; false o dulent.
(Witness) (Address61
Y
s
(Signature of Riflative or/.Leg`al Rep. and Address)
signed on this date: