Smith, Keeghan TOq4N OF QUEEVBU9�yPINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director )� C ce'4 U
Name (.�,('rf�bl'� �j� '�'t" Case# C,
Date Of Cremation
Time Cremation Started
Time Cremation Completed
Type of Container OJA mD 13dt*2
Remarks c�
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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 Regulations to Cremate the remains of:
tom4 ,�' �1, no a�
(Name) (Sex)
(Street) (C y) (State) (zip)
who died on day of a cbc:, 20 "
at 7J21;21)
(Place) (Address)
Name and address of nearest relative or name of person Authorizing cremation: J
T f L ✓� �lt'N�x- � 9l f.Y-c�.-L3'%r�S. `i' �t Sr.a_n ���i )
(Name) (Address) /
Relationship to the deceased
Name of Funeral Home
IMPORTANT:
I represent that to the best of my knowledge, the deceased has r has no acemaker in his ocher 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 from any
and all claims and demands for loss or damages which may be made against them by reason of or
connected with the crematio said remains as directed, whether such claims or dergands are or are not
wholly groundless, fals rau went.
Lq
Witnes (Address)
(Si nature of Relative o Legal Rep. and Address))
Signed on th' ate: /v 3