Phillips, Martin TOWN OF QUEENSBURY
Piece View Cemetery and Crematorium
21 Qunker Rond, Queensbiiry, NY. 12804.5902
(518) 745-4476 (518) 745.4477
http://w\{nv.queensbury.net
Funeral Director: _,/✓l 1�J1�1'< �=�Z- /
Name of Deceased: /
Case Number: 44 n
Date of Cremation: �/ ! — 2cz .�L
Retort: C g 4 u
Time Cremation Started: 1 b �-
Time Cremation Completed:
Type of Container: C �! G�ts �'�` ✓'� i'4 ��
Remarks:
'3c�� �
i y o �"�.
TOWN OF QUEENSBURY /„
PINE VIEW CEMETERY
CREMATORIUM
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:
mogrt I AJ j�h I It ,ate I`T
(Name) (Sex)
S(-hKran R,�c9 Alt/
(Street) (City) U (State) (Zip Code)
who died on day of AJl> yrrnbe4- 19-9 ��
at 11"'S 0-L&S &-'�P�
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
(Name) (Agess)
Relationship to the deceased �6�g2&
Name of Funeral Home K utalmf' �
IMPORTANT: 4
I that to the best of my knowledge, the teceased has or
in his or her body. (Circle One)e,
I certify that I have the full power and authorizption to arrange
for the cremation of the remains and to direct-'thp,, disposition of
the cremated remains, that any personal possestons have either
been removed or may be destroyed, and- agree to ptbtect, 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.
'- (Witness) (Address ) V
Y'
(Sign ture of Relative or Legal Rept 9nd Address)
Signed on this date: r 0 Y-0