Burgess, Garvin TORN of QUEEVBU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director A4
Name u'p4't V ) (ljc9CL G,l;ys Case# '7 6
Date Of Cremation Y 'L Czr — 'Z O C)
Time Cremation Started 3 4
Time Cremation Completed /d �l
Type of Container "yz ) oeA4y,
Remarks
I LA y A4/)4- Fg-A-1
i� 35"
TOWN OF QUEENSBURY L/
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 witr) ano sublect
to its Rules and Regulations to cremate the remains of:
aN;/\, 13 A 0%1 01 Le-
(NAME) (SEX)
to C'-' . / klu �. Ij1f / aKa--?—
(STREET) (CITY) (STATE) (ZIP CODE)
r
who died on '-T ��wY day of / V 20 O Af—
(PLAC (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation
Relationship to deceased t�
r S
Name of Funeral Home t15„� n�
Y.l
{m,
IMPORTANT
I represent that to the best of my knowledge, the deceased has o n 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 whicp may be made
against them by reason of or connected with the cremation otsaid remains as directed, whether
such claims or demands are or are not wholly groundless, false or fraudulent.
(WITNESS) (A S)
o� Cam. O �ZZ
(S1GtaTL0t0 RELATIV60R LEGAL REP. AND ADDRESS.).
Signed on this date: