Loading...
Carr, Nancy TOWN OF QUEENSBURY Pine View Cemetery and Crematorium 21 Qunker Rond, Queenshury, NY. ]2804-5902 (518) 745-4476 (518) 745.4477 h(tp://wwNv.queensbury.net Funeral Director: /✓) A ��'I/ b K) S S Q // S Name of Deceased: G 'V� kl Case Number: 3 LA Date of Cremation: Retort: Time Cremation Started: / 3 d r"v Time Cremation Completed: &I Type of Container: Gc-)1-4 1-?- Remarks: D A-t/ " Home of N n t u r n I Beauty ... A Goo i P I n c e to Live " i TOWN 01=QUEENSBURY PINE VIEW CEMETERY 3 3 L/ 8 ] CREMATORIUM Quaker Road, Queensbury, New Yoik 120U4 Phone(510)Crematorium 7454477(if no answer) Cemetery 745A4.76 AU1110RIZATION 1-0 CREMA'rL= The undersigned requests and authorizes Pine View Crematorium. in accordance with and subject to its Rules and Regulations to cremate the remains of. Wa_Acu AA On rr- (NAME) (SEX) -015e7iv s f. 9 aQ- n APO/,/)-/- W, Y. /a 9�' (STREET) (CITY) (STATE) (ZIl'CODE) who died on o30 Y-A day of at cab* -/, down COM ML4 / V-(_. (PLACC) (ADDRESS) Name and address of nearest living relative or name of person authorizing cremation: _L a-r- �� e S�1 , Fc�r. a o3'7 Y S Zfe 9/V Ti Cap,d er-a�a/ /V, ia�e3 Relationship to deceased s©n Name of Funeral lione , ( i co YI IMPORTANT I represent that to the best of my knowledge,the deceas has r ftqULo pacemaker in I►is or her body. (CIRCLE ONE) 1 certify that I have the lull 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 tray 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 lire cremation of said remains as directed,wiheliher 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: 1 !—O S