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LaForest, George S TOWN OF QUEENSBURY Pine View Cemetery and Crematorium 21 Quaker Road, Queensbury, NY. 12804.5902 (518) 745.4476 (518) 745.4477 http://w%vw,queensbury.net Funeral Director: Name of Deceased: ly' c�C- ,c L►- �"' >A �© �2 e.� Case Number: Date of Cremation: Retort: G Time Cremation Started: 1 5 Aq Time Cremation Completed: 1 s Type of Container: IA q-� (o_ Remarks: in 13 �� ' PAIA " Home of Natural Beauty ... A Good Place to Live " ;Fdo'l 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 nd Regulations to cremate the re ains f: v Sex N Street City State Zip who died on day of -1 �. 20 at L �� placeAdd Nam nd address of nearest liv' rel tive or name of person authorizing cremation Relationship to ased' :�� Name of Funeral Home MILLER FUNERAL HOME Indian Lake, NY IMPORTANT I represent that to the best of my knowledge,the deceased has has no Pacern�cer i his or her body(CIRCLE ONE) I certify that I have full power and authorization to arrange for the cremation of the remains and to direct the disposition of the crenated 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 damage s or dam- ages which m.a made against them by reason of or connected with the cremation of said remains as directed,whether ad, wheteher such claims or ands are or are not olly grpunliess,false or fr du t. Witness Ad ess (S ATURE OF RELATIVE OR LEGAL REPRESENTITIVE) signed on this date l(J