Andersen, Elsie TOWN OF QUEENSBURY
Pine View Cemetery and Crentntoriunt
21 Qunker Rond, Queensbury, NY. 12804.5902
(518) 745-4476 (518) 745.4477
hltp://wNv%v.queensbury.net
Funeral Director: 16,01 v LIGCA-
Name of Deceased: Ogg-/- Nd r—R S Q/ K)
Case Number: ZS
Date of Cremation:
Retort: 09A LU(�b fz�
Time Cremation Started: 1_ Iv
Time Cremation Completed:
Type of Container: GrkcJ R` t4 414 V" �V
Remarks:
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" Home of NntitrnI Benitty ... A Good PInce to Live "
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TOWN OF QUEENSBURY <�
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 1204
Phone(610)Crematorium 7454477(if no answer)
Cemetery 7454476
AUT14ORIZATION 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.
-/'�- --7— rLiLht /;M,* h:-
P
r (S�)
9 RA,,U,- Lm . brJ
(STREET) (CITY) (STATE) (ZIP COD )
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who died on� b� day of 20 Q�5'
at
(PLACE) (ADDRESS)
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Name and address of nearest living relative or name of pe on aulliorizing cremation:
Relationship to deceased
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Name of Funeral Home
IMPORTANT
I represent that to the best of my knowledge,the deceased LLas or ras r acemaker in his or her
body. (CIRCLE ONE)
certify tiiat I have the full power and authorization to arrange for the cremation of tine 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
,d—re malorium from any and an 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
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(WITNESS) ( ESS)
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(SIGNATURE OF RELATIVE OR LEGAL RE.AND ADDRESS)
Signed on this dale:_
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