Joseph, Theodore ti
TOWN OF QUEEVBU-I y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name 2fi)9WE 6 Case#
Date Of Cremation f -- Z 2 -0
Time Cremation Started J ' ✓l,
Time Cremation Completed �� —
Type of Container_' g-vj1 c) Az-()
Remarks
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12804
Cemetery Office: 518-745-4476,Crematorium: 518-745-4477
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:
(Name) (Sex)
(;a3 - �' - AJ X /2,W
(Street) (City) (Sta1 ) Rip Cam)
who died on �;L 1 day of ;F CE'(Y\;o 20joJ-
at 9LEvs TA7 o- s kIoSgy7lll 1cyv Palms s t a ft �
(Place) (Addiwo
Name and address of nearest living relative_or name of person authorizing cremation:
6-2- f�,s�� l � D l�4L�r� "
(Name) /� (Address)
Relationship to the deceased v G'✓ l Sv
Name of Funeral Home F'cU
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has) (has no pacemaker,defibrillator or any other battery operated
device in his or her body. (Circle One) 01(
I certify that I have 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 ad claims and demands for loss or danheges 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
grouzz
or ulent.
f - Reec f!3 ft o C1
(W' ) (Address)
(Signature of R or L I Representative) in�r.�+c%f
Signed on this date: E 2ao,5
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to of tlhe remains as follows:
Mail to
12 CS��
Other arrangements-Please specify:
If ptfver¢ation of cremated remains is requested,check here
Revision:July 7,2004 Theodore Joseph
233 Ottawa St
Lake George NY 12845-1110