Pensel, Donald TOWN OF QUEENSBURY
Pine View Cemetery and Crenintormin
21 Qunker Rond, Queenshury, NY. 12804-5902
(518) 745-4476 (518) 745-4477
http/iwww.queensbury.net
Funeral Director: uh t P2n
Name of Deceased: Pond 4 Pe n SG�
Case Number: `1-�-�
Date of Cremation: I o
/► �
Retort: C r ci w fro r 4 15 C,�,
Time Cremation Started: 3 A M
Time Cremation Completed: 10 2c) A M
Type of Container: �cj ko4yj---
Remarks:
mti�n 1: 1-I0 All . /q N
Y : ys A .H
H /0 1
I
I
I
•` TOWN OF QUEENSBURY (p 3
,.� 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 a^ �? Vnnd\Regulattions to Cremate the remains of: �
1/oy,Jd- t &c) '-)yr?1`_
(Name) (Sex)
/ 70 L)J P Y .T Cs7 A-
(Street) (City) (State) (Zip
who died on '` t j' day of c ern�6 1 r 20 Q S
at
(Place) (Address)
Name and address of nearest relative or name of person Authorizing cremation:
(Name) (Address)
Relationship to the deceased <<
Name of Funeral Home
YR Y t
IMPORTANT:
I represent that to the best of my knowledge, the deceased has o has:n emaker in his or 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 removFd
or may be destroyed, and agree to protect, defend and save harmless Pine View Crematorium from ary
and all claims and demands for loss or damages which may be made i3gainst 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.
(Witness) (Address)
(Signatfire of Relative or Legal Rep. and Address))
Signed on t ' .late:
X Vv VV
,