Underwood, Milton a
TOWN OF QUEENSBURY
Pint View Cemetery and Cremn tort um
21 Qunker Ronr(, Queenshury, NY. 12804.5902
(518) 745.4476 (518) 745.4477
htrp iiw\v\v queensbury net
Funeral Director: P'l 9 1 M ou-e—
Name of Deceased: M% 16\ D A av r .v d
Case Number: 3 7-2\
Date of Cremation: 5 f 210
Retort: rr5 w rd
Time Cremation Started: VA
Time Cremation Completed::
Type of Container: ( `� r4 I ,ot l0
Remarks:
� , mt n nt !trn1 8enuly . A Cond Plnie in Live
TOWN OF QUEENSBURY ✓ ? 2--
. „ PINE VIEW CEMETERY
8
CREMATORIUM
Quaker Road, Queensoury, 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:
�'.. (NA)Fier N,t(, (SEX)
12 MkX 5t. Vc /l1• Z �37
(STREET) (CITY) (STATE) (ZIP CODE)
who died on day of 20 b Y
at u , der 1-7 ��,L,r 5zz Gf�ca.+ Re
(PLACE) (ADDRE S)
Name and
address of nearest living relative or name of person authorizing cremation:
Relationship to deceased
Name of Funeral Home S,,,,,c
IMPORTANT
I represent that to the best of my knowledge, the deceased has or has no pacemaker n 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 cl ms A;emds are or are not wholly groundless, false or fraudulent.
��tr �s are 7 6Ns A-M g�2
NESS) (ADDRESS)
�(s
4�` /,—/ btu�-t_ h-IGNATURE OF RELATIVE OR LEGAL RFzP. AN ADDRESS)
Signed on this date: e OD