Wendell, Frederick TOWN OF Q UEENS B UR Y
Pine View Cemetery nnrl Crenintoniiin
21 Qunker Rond, Queensbury, NY. 72804.5902
(S18) 745�4476 (S18) 745.4477
h(rp iiwww queensbury net
Funeral Director: l�C� \ �- C�i C)A-- �
Name of Deceased:
Case Number:
Date of Cremation: ' ( t s-
Retort: C, C)-\ -vz�w
Time Cremation Started: 41 5—
Time Cremation Completed: ( O M�
Type of Container: C,t4 �a 1A1 Q 1�
Remarks:
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H o m of NnturnI Benuty ... A Con �t PIn ; r to L r
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TOWN OF QUEENSDURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone(518)Crematorium 7454477(if no answer)
Cemetery 74544.76
AUT14ORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in accordance Willi and subject
to its Rules and Regulations to cremate the remains of.
(NAME) II (SEX) /J
-Y
(STREET) (CITY) (STATE) (ZIP C E)
who died on day of ail 20
at Mcze-s
c--�
(PLACE) (A DRESS)
Name and address of nearest livin relative or name of person au0iorizing cremation:
/ ' ... 1-41 r
0
Relationship to deceased
JX�L-
Name of Funeral Home W !4 W
IMPORTANT
1 represent that to the best of my knowledge, [lie deceased has or ias 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 tiie 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
,dre m lodurn from any and al 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.
(WITNESS) (ADDRESS)
SIGNATURE OF RELATIVE OR LEGAL REP.AND ADDRESS)
Signed on this date: