Kenerson, Oliver r"0HIN OF QUEE BW
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name ®�lVL�12 '�(�1JIZSU��I Case# F�
Date Of Cremation jCj Tz" Z-tJ�- r7
Time Cremation Started C V rn
Time Cremation Completed , Z `�cam_ � . /
Type of Container (�ft(a j Cj,�,� {� � i� - /� Z a2
Remarks
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TO 3 WN 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 Regulations to Cremate the remains of:
(Name) (Sex)
+� ar r-\S Q-��J Y)
(Street) (City) l to ) (Zip)
who died on
day of 20 .
at MG S S C ,lL 1��-P OS 40-o
(Place) (Address)
Name and address of nearest relative or name of person Authorizing cremation:
(Name) (Address)
Relationship to the deceased
Name of Funeral Home �^ i -O�n 47
r
IMPORTANT:
I represent that to the best of my knowledge, the deceased has has no acemaker in his Qr,her'body.
(Circle One)
I certify that I have the full power and authorization to arrange For the mation of the remains and to�
direct the disposition of the cremated remains, that any personal possesns have either been removed
or may be destroyed, and agree to protect, defend and save harmless Pine View Crematoriums from any
and all claims and demands for loss or damages which may be n-#de e9ainst them by raOson of or
connected with the cremation of said remains as directed, whether suqL.clai.ms or demands are or are not
wholly groundless, falsept fraudulent. r
(Witne ) (Address) z
nn
(SigrrAture of Relative or Legal Rep. and Address))
Signed on this date: