Dickinson, Richard T- O- q+N OY QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director—.--,..
Name i \ C44tkLd ��C�K( l� �) �,( Case# �'!� C ::�;
Date Of Cremation
Time Cremation Started
Time Cremation Completed 1 P(At
Type of Container ���t r� _�' 6�'i 1,4
Remarks I
TOWN OF QUEENSBURY �j 1
F. 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:
(Name) (Sex)
(Street) (City) (State) (zip)
Am-
who died on day of 20
at
(Place) (Address)
Name and address of nearest relative or name of person Authorizing cremation:
(Name) (Address)
Relationship to the deceasedo
Name of Funeral Home G L
IMPORTANT:
I represent that to the best of my knowledge, the deceased has r has po a ker in his or her body.
(Circle One)
I certify that I have the full power and authorization to arrange For the n of the'remains and to,
direct the disposition of the cremated remains, that any personal posse have either,Wen removed
or may be destroyed, and agree to protect, defend and save harmless iew Crematorium from any
and all claims and demands for loss or damages which may be made "einst them'by reason `of"or
connected with the crematiop of said remains as directed, whethea or demands are or are not,
wholly groundless, false or udulent.
(Witn ss) A (Address)
(Signature of Relative or Legal Rep. and Address))
,.. r
Signed on this date: 0 2`