Jay, Amy lou e
TOWN OF QUEENSBURY
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, NY. 72804-5902
(518) 745.4476 (518) 745.4477
http://w%v\v.queensbury.net
Funeral Director: o �3 ✓� U ��
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Name of Deceased: ci
Case Number:
Date of Cremation: l 2-CJ —
Retort: TIEI
Time Cremation Started:
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Time Cremation Completed:
Type of Container: clo v2o �3c��t Z�
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Remarks:
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" Honig of Natural Benuty ... A Good Plnie to Live "
JAN-19-2006 11 :56 PM P. 01
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office:(518)745-4476,Crematorium: (518)746-4477
Authorization to Cremate
The unders peed requests end aulhortres Pine View Crematorium,in socordwoe with and sA4m to its Rules and Repulett m to
cremate"rremaks of:
(Name.)
( ) (C (Stare) (zto code)
who died on / 7h _ day of h a.t'l
2D�at �l�ny��//A+yC�/Tt�a.Ohci/ �s.e0oll �N
MIMM) )
Name and address of nearest Oft raw dve or name of person suuvgt nit cremadon:
(Name) (Addroes)
ReMim ehlp to the deceseed___,/.�''" 7fr/
Name of Funeral Home E' S
N PMANT: dofbrlkWr or any other batiery cparated
I represent that b the tact of my W0N%dpe,the deosase
device In his or her body. (Ck de one)
1 cm*Uat i hew fuN power end autlnortrvtion to airenpe for the aemretion of the memlns and to dkW the� POWticn to protectadstend and
the
,��cr mwaka,that any pereanal powmak r>s have either been removed or may etr
y be deoyad,and
sous ttamnlasa Pine View Crasabrhm from any and ON dakns and demands for lose or demapss which may be made epaknet#"m
by reason of or amocied with the owneNon of said remrakia m directed.whatl►er such ddms or demands we or ors not wholly
=tob
t/C
7-04e--
(`+yam) (/lddrass)
ReWtve or LeoRepreeentatlw)
DWpos%m of Cremated Remains
I hereby dkact pine View QemeWd=to dispose of the awnded Mrnains es MOWS.
Map to
0dw a"Weenaenls-please sped"
If p Averustim of cremated nanalro is requested,check here
Revision:JenumrY 1,2M