Betts, Richard a
TOWN OF Q UEENS B U"R Y
Pule Virtu Cemetery nir(1 Cremn tort ufit
t 21 Qunker Ronri,
Qirernshury, NY. 12804.5902
(518) 745.4476
hirP llw\v v queensbury net (518) 74 5.44 77
Funeral Director: F' GA vN ---pa-��V i
Name of Deceased:
Case Number: Ce
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Date of Cremation: — Z�l— '0cv
Retort: C IR,"
Time Cremation started:
Time Cremation Completed:
Type of Container: a 2"
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Remarks:
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TOWN OF QUEENSBURY Y
PINE VIEW CEMETERY&CREMATORIUM
Quaker Road, Queensbury, New York, 12804
Phone(518)Crematorium 745-4477 of no answer Cemetery 7454476
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:
Tir.l 'J
(Name) (Sex)
L4
(Street) (City) I (State) (Zip) .
who died on 2(,:.-,• ?oo day of 20 6 V
at 6% P-(W Ob fAkL 'Si-. G kn Car-,
(Place) (Address)
Name and address cif nearest relative or name of person Authorizing cremation:
�►h►irteu �. c,z , Atklesg way, Qbu. N�J
(Name) 3 (Address)
Relationship to the deceased tk) ( �L
Name of Funeral Home `
IMPORTANT:
I represent that to the best of my knowledge, the decease has r A� 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 them by reason of or
connected with the cremation of said remains as directed, whether such claims or demands are or are not
who gr ndless, alse or fraudulent.
(Witness) 1` (Address)
(signature of tKelative or Legal Rep. and Address))
Signed on this date: t Z 6-;