O'Neill, Daniel TORN OF QUEEVBU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 'Ry)3f,�44 P OR f ��
Name �1.1�(,� (� ���51, Case# 6- e
Date Of Cremation
Time Cremation StartedM-
Time Cremation Completed Q
Type of Container \e�3G1ALZ
Remarks
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04/30/2004 09:36 518-745-4445 TOO COMPTROLLER •PAGE 01
TOWN OF QUEENSBURY 5�
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 with and subject
to its Rules and Regulations to cremate the remains of:
V J � .
(SEX)
r-� (NAME) /- �o
(STREET) (CITY) (STATE) (ZIP CODE)
who died om �I day of �VGer� ' 20Sr ,
0
et � ADDRE
(PLACE)
Name'and addjress'of nearest living relative or name of person authorizing cremation.
Relationship to deceased / c3 ,✓
Name of Funeral Home
IMPORTANT pacemaker in his or her
I represent that to the best of my knowledge, the deceased hn or has no p
►ody. (CIRCLE ONE)
I certify.that f have tha 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 them by reason of or connected with the cremation of said remains as directed, whether
sins or a and re r not wholly groundless, false or fraudulent.
Y
( SS) ( DDRESS)
(SIG NAT F RELATIVE OR LEGAL REP, AND ADDRESS)
Signed on this date: