Taylor, Philip rr0 WN OF QUEENSBU-r�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director / b
Name�l �� , " 1. ft'�-;� !�` o CL Case# �l
Date Of Cremation
Time Cremation Started
Time Cremation Completed
Type of Container � `1� � �Z(� �,� y ���`� '7,2��
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:
(NAM ) U U (SEX)
3 J -,� -
(STREET) (CITY) (STATE) (ZIP CODE)
who died on day of n - 40
at r- /
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cfemation:
QJ
^..
Relationship to deceased ��
Name of Funeral Home 1;�7
IMPORTANT
I represent that to the best of my knowledge, the deceased ha or h aker in his or her
body. (CIRCLE ONE)
I certify that I have the full power and authorization to arrange for the,'-[ of"ttl)e° etrl8ins and
to direct the disposition of the cremated remains, that any peSonal jssessions'haver been
removed or may be destroyed, and agree to protect, defend antiharmless Pine V*
Crematorium from any and all claims and demands for 1040. 11111183s Which may be made
against them by reason of Or connected with the cremation, said remains as directed, whether
such claims or demands are or are not wholly groundless, figse or fraudulent.
(WITNESS) (ADDRESS) °.
I
SIGNA R 0 RELffE OR LEGAL REP. AND ADDRESS)
Signed on this date: 0 oZ — O