Jenkins, Willard rrnWN OF QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name � � � �K11�✓ Case#
Date Of Cremation
Time Cremation Started /Q ., 3 -j
v
Time Cremation Completed Q }7
Type of Container G4V-D&14 1'2v ,M �g X ti0 ; 25� ✓ +(�
Remarks
�2-14,
fZ C-Ir
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
_o (Name) (sex)
(Street)) (City) /� (State) (Zip Code)
who died on 1 R e. 9 1 / day
'off 1J,e-C,9 W1 20 US '
at CO 1C'4;S Ac 11 pi/P
(Place) (Adder)
Name and address of nearest living relative or name of person authorizing cremation:
WAi-reY HC+�Klr�►y �� 1~n-�yLTcw i& Clrn s1Gd c'i lle- N._Y• 24;6- 7
(Name) �� ``(Address)
Relationship to the deceased .fit;N
Name of Funeral Home PdAj i4 4• rUN C r'P/ N lw e
IMPORTANT:
I represent that to the hest of my knowledge,the deceased(has)or(has no) maker,defibrillator or any other battery operated
device in his or her body. (Circle One)
I certify that I have full power and authortMion 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 of or connected with the cremation of said remains as directed,whether such claims or demands are or are not wholly
t7l
grounb4s.few
iuy lid
( ess)
0�
( of Rlelative� or Legal Representative)
_
Signed on this date: L 'x
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to tY
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
Revision:July 7,2004