Smith, Thelma (-rnrWN of QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director-
Name n' I—JK Case#
r—
Date Of Cremation 2- [ -7,
Time Cremation Started �6
Time Cremation Completedl.
Type of Container '14Y+
Remarks
Ct
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TOWN OF QUEENSBURY �
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\Reguulations to Cremate the remains of:
\
Yl-c 1 rri �Vr;4-)6 /C C
(Name) (Sex)`
(Street) (City) ( tate) (zip)
who died on l L' day of ��= � 20
at
(Place) (Address)
Name and address of nearest relative or name of person Authorizing cremation:
L.. 5
(Name) (Address)
Relationship to the deceased S -
Name of Funeral Home Xc
IMPORTANT:
I represent that to the best of my knowledge, the deceased has o ha�nocemaker in his qr 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 f*any
and all claims and demands for loss or damages which may be mad# against them by reaq or
connected with the cremation of 'd remains as directed, whether such Maims or demands are-o Sara not
w d wholly groless, false or dul nt.
L °
( itness) (Address)
X
(Si atu Relative or Legal Rep. and Address))
Signed n this date:
X00G�
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