Haigh, Andrew a
TOWN OF Q UEENS B UR Y
Pine View Cemetery and Cremn tort itrn
21 Qunker Rood, Qieenshury, NY. 12804.5902
(518) 745.4476 (518) 745.4477
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Funeral Director:
Name of Deceased: A v�) 1Z e L ) 1 i 44-%(y K
Case Number: 3 Z
Date of Cremation:
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Retort: T C r�
Time Cremation Started: ';4 p Ak
Time Cremation Completed: � -
Type of Container: C- '
Remarks:
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r� omc n,f .NnIiirnl Benuty . A Cond PInie to LiL)
TOWN OF QUEENSBURY �� V
PINE VIEW CEMETERY&CREMATORIUM
Quaker Road, Queensbury, New York, 12804
Phone(518)Crematorium 745-4477 of 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:
)find-'-zw _ Via:0 yw,2,
(Name) (Sex)
(Street) (City) (State) (Zi
who died on �2/ day of Sc,o i< 20 CS
at
(Place) (Address)
Name and address of nearest relative or name of person Authorizing cremation:
L,v, )1; )40,4�
(Name) (Address)
Relationship to the deceased
Name of Funeral Home to
R
IMPORTANT:
I represent that to the best of my knowledge, the deceased has o ha�no acemaker in his or her body.
(Circle One)
I certify that I have the full power and authorizatiorV to arrange For the cremUthe vemairls and to
direct the disposition of the cremated remains, that any personal possessions ither been tembvbd
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 riot
wholly groundless, false or fraudulent.
(Witness) (Address)
(Signature of Relative or Legal Rep. and Address))
Signed on this date: