Sutton, Howard TORN OF QUEEVBU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director C-.,4)9 Al 4—c) KI
Name 40VAT?--� S f2l Case# 1-1�5- 5
Date Of Cremation C)
Time Cremation Started 1 '2, `7�� P:�il
Time Cremation Completed
Type of Container Ci •d
Remarks
� P�
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM r
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if 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:_
DUJA�_J jAMeS 50-++00 ]Trz— al A-
(Name) (Sex)
00 rSo04 6p12-141n20 S-f- ova � ..
(Street) (City) ( tate) (Zip Code) .
who died on a day of �0+0 �'-q i - -00
at 1,eN5 PAk\S 4050k, VY0 , Gip-,vs FP- 1(51 /\-JyJ--'Sy/
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cr.emptions:
i Iq� �,rJ �:�-� -�►� Boa 5����h G/�R I�Nc%Sf �wjatk10 �oaa.6
(Name) (Address)
Relationship to the deceased
Name of Funeral Home Gm-s]:etenF Hare ine.
IMPORTANT:
I represent that to the best of my knowledge, the deceased h.as or as no
pacemaker 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 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 t#lem .
by reason of or connected with the cremation of said remains as directed,
whether such claims or demands are not wholly groundless, false or fraudulent.
(Witness) (Addf ess) #
? r
(Signatur Rela ive or Legal Rep. and Addressl
Signed on this date: