Ackerman, Leslie a
TOWN OF QUEENSBURY
Pine View Cemetery rind Creninlnrinni
21 Qunker Rond. Qieenshury, NY. 12804.5902
(518) 745.4476 (518) 745.4477
hirp iiwww queensbury net
Funeral Director: F,
Name of Deceased: Pt t\(
Case Number:
Date of Cremation: c) S'
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Time Cremation Started: til
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Time Cremation Completed: �� � ` j
Type of Container: 04,�) Z301-:�k,-2-d y '1 2D 14- 11
Remarks:
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Town of Queensbury
Pine View Cemetery
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:
�e61 ; e-, M Ackcrry-n-n ,AJ 6JC—
Name Sex
I rD nda ak•e? Rd rid rah Laky,_ J\Y I Za
Street City State Zip
who died on J day of ,t Cl I J'si 20�_
at 6d
'
ply Address
Name and address of nearest living relative or name of person authorizing cremation
Relationship to deceased '
Name of Funeral Home MILLER FUNERAL HOME ";• ,• I
Indian Lake, NY
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IMPORTANT r
I represent that to the best of my knowledge,the deceased bM or has no pacemaker in his or her body(CIRCLE ONE) ti
I certify that I have full power and authorization to arrange for the cremation of the remains and to direct the dispaadior t
of the cremated remains,that any personal possessions have either been removed or may be destroyed,and agipe
to protect,defend and save harmless Pine View Crematorium from any and all claims and demands for loss or damage s or dam-
ages which m;a made against them by reason of or connected with the cremation of said remains as directed,whether ed,
er such=demandse or are not wholly groundless,false or fraudulent.
W ess Address
ZNATURE OF RELATIVE OR LEGAL REPRESENTITIVE)
signed on this dat
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