Timms, Charles TOWN OF QUEENSBURY
Pine View Cemetery and Crematorium
21 Qunker Rond, Queensbury, NY. 12804.5902
(518) 745-4476 (518) 7a5-4477
hup//wNvw.queensbury.net
Funeral Director: ; 9 • k / ) m Q, /,
Name of Deceased: C�{1 AR 1 QS �/ 1'Vl rYIS
Case Number: a,70
Date of Cremation: 6
Retort: C hA-141
Time Cremation Started:
Time Cremation Completed:
Type of Container: Q k-Aa 130�w�
Remarks:
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" Hong of Nnturnl Benitty ... A Good Plnie to Live "
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road. Queensbury, New York 12804
Phone (518) Crematorium 745-4477 (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:
C # /49//,� Ti Val YK S
(NAME) (SEX)
(STREET) (CITY) (STATE) (ZI CODE)
who died on day of 20
at
(PLACE) (ADDRESS)
Name and address of nearestliving relative or name of person authorizing cremation:
4AIAl
Relationship to deceased uJ
Name of Funeral Home �`'6 ` ��L ow
IMPORTANT
I represent that to the best of my knowledge, the deceasedig1poro 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 wr the cremation of said remains as directed, whether
such claims or errands are or e n t w Ily groundless, false or fraudulent.
(WITNESS) (ADDRESS)
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS) j
Signed on this date: ��