Hickey, Laurie "'UN OF QUEEN5BU9 y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director Den S rn4) r--c
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Name �Wu'r5 if Case#
Date Of Cremation it /11 /U`i
Time Cremation Started
Time Cremation Completed 1I2 f7 GM
Type of Container CGr�( vUu� �{; E Cc,
Remarks
3 y A .M 10 A�
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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 suolect
to its Rules and Regulations to cremate the remains of:
A .
G, (NAME) (SEX)
ao Limer C: I C4,
(STREET) (CITY) (STATE) (ZIP CODE)
who died on day of L—� 20 D
at
(PLACE) (ADDRESS)
Nameand address of nearest living relative or name of person authorizing cremation
/ Ve- /
Relationship to deceased e
Name of Funeral Home
IMPORTANT
I represent that to the best of my knowledge, the deceased has has,-no pacemaker i his or ner
body. (CIRCLE ONE)
I certify that I have the full power and authorization to arrange for the cremation of the remains ano
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 from any and all claims and demands for loss or damages which may be made
against them by reason of or connected with the cremation of said remains as directed, whether
such claims or demands are or are not wholly groundless, false or fraudulent.
v
(WITNESS) (ADDRE S)
aD VP f:'
(SIGNATURE OF RELATIVE 09 LEGAL REP. AND ADDRES )
Signed on this date: J—