Haupt, Aidan i
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TOWN OF QUEENSBURY
Pine Vieto Cemetery and Crematorium
21 Qunker Road, Queenshury, NY. 12804-5902
(518) 745.4476 (518) 745.4477
hire://ww%v.queensbury.net
Funeral Director:
Name of Deceased: '1� U 'iiA w AL)`P`T
Case Number:
Date of Cremation:
Retort: �
Time Cremation Started: �''�-O 1�
Time Cremation Completed:
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Type of Container: �K�����d I�fi
Remarks:
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" Howe of Naturnl Benuty ... A Cood Plnie to Liue ''
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or 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:.
(Name) I (Sex)
1 1 �5o u�-h v a e cc) Df . I W a-C_ /a n �-
(Street) (City) I (State) (Zip Code)
who died on day of Atotic a
at 61e n, i7vSIE,azc—L ', A�o
(Place) (Address) c' A,
Name and address of nearest living relative or name of person authorizing cremations:
`loQ v7r)C /c-a-c.e-p C I �vu,a�1 v ;Q 60l.
(Name) —(Address)
Relationship to the deceased M ° Aa✓
Name of Funeral Home Ea-iete Fune.-ial He ff...
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or (haso
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 t#iem
by reason of or connected with the cremation of said remains as directed,
whether such claims or demands are not wholly groundless, false or fraudulent.
(Witness) (Address)
Y—L] �-
(Signature of Relative or Leg I Rep. and Address.l
Signed on this date:
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