Plummer, Noeline a
TOWN OF QUEENSBURY
Pine Virtu Cemetery and Crentntortttnt
21 Qunker Rond, Quernshury, NY. 72804.5902
(518) 745.4476 (518) 745.4477
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Funeral Director: -3 L►�1. �./ ��
Name of Deceased: ti�lC7�i�, L ti �, j.�J /, /V �
Case Number:
Date of Cremation: S6 f 2 6C. i
Retort:
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Time Cremation Started:
Time Cremation Completed:
Type of Container; �'ib4�� " ✓-i- v �} ,1y
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Remarks:
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY '2 r? Q
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 and Regulations to cremate the remains of:
J0f,e\\t1Q �' onoMe C
(NAME) (SEX)
(STREET) (CITY) (STATE) (ZIP CODE)
who died on day of 20
at (l�k �� (j f
(PLACE) (ADDRESS)
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Name and address of nearest living relative or name of person authorizing cremation:
Relationship to deceased �nyG�1
Name of Funeral Home e
' j
I
IMPORTANT
I represent that to the best of my knowledge, the deceased has or has 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 tie-rema'irls.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,UxT by reason of or connected with the cremation of said remains as directed, whether
suc i or demands are�orre not wholly groundless, false or fraudulent.
(WITNESS) (ADDRESS)
(SIGNATU EnOF RE TIVE OR LEGAL REP. AND A ES )
Signed on this date: 7 &
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