Arcaro, Golde TOUN OF QUEEVBUI�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name Cqo td f/ Case# tj
Date Of Cremation �, � �� 2.U0
Time Cremation Started RtiA Q V �
Time Cremation Completed �-
Type of Container 1Z 2jCX4 Iz
Remarks
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
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CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 (if no answer)
Cemetery 745-44,76
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:
CA carte .
(NAME) (SEX)
tj . /H l� v r, A `� a 2-
(STREET) (CITY) (STATE) (ZIP CODE)
C� �
who died on day of D C<. ,.tj 20 05
(PLACE) (A T
RESS) i
Name and address of nearest living relative or name of person authorizing cremation
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Relationship to deceased
Name of Funeral Home e M o r f r r
IMPORTANT
I represent that to the best of my knowledge, the decease Chas)lor has no pacemaker in his or ner
body. (CIRCLE ONE)
I certify that I have the full power and authorization to arrange for the cremation of the remains ana
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 cremation of said remains as directed. whether
such claims,,w demands are or are not wholly groundless, false or fraudulent.
>M�- S er K A, ,r: A )
ITNESS) (ADDRESS) '
(S IY61TURE OF RELATIVE YR LEGAL REP. AND AD RESS)
i
Signed on this date: CC o`'5