Cook, Emily TOUN OF QUEEVBU9 y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
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Date Of Cremation 2, _ ) Z�0 (o
Time Cremation Started '2—o PA �✓�
Time Cremation Completed
Type of Container G�,+1ZD 1304VZJ A4 YetA S��9 't,
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
Auftrization to Cremate
The oWosipnad requersis and ae*o UM Pine View CromaWrium,in accordance w4h and%Med to ns Rules and Reyulatiorra to
cremate the remains of:
16
A Aje)el '4T C A/JL
( ) (Cory) (stores) ( )
who died on _�_ day ofat
U X V -�--�F'
(per) (�Wdrees)
Name and address d relative or warns of person a giat p ^
777,,���n �,,- -r��
( ) (Addrow)
RekMora>W to 1ha deoeeed - •�
Name d Fumed Home
IMPORTANT: elibrlNaior tX any di fer banar�operated
I represent!flat to the bead of my WoWedg%the dWWAod(tree) (!roes no)paoernar .
device in his or roar body. (Circle One)
I cerwy dw I ton"power and won to WNW for the aemeMon of the remains and to diced the dWoskion of the
rremood nMwW s,ihet any pwswar poM"Mons have wirer bean romoved or may be deedroyad.and spree b Pfded,defend and
sari h MIM Pine View CrW Wrim*M any and al claims and dernards for toes or dMuMM which may be made apairrst theme
by rowan ofor Wkh the d said remains ss d mdA whether ardor dok- or dmr Wft are or are not v*l*
(
(Somwim acid Addma d Re/let(ve or I.epel�epreeentealke)
sienea on this date:
Disposition of CmmMod Rarneins
I hereby thread Pine View Cren o)rk m to diaposa of the c lad MM*M as tdlaM►e;
Md W
Other wranpemerrts-Please sped(y:
If pulverization of cmmood remema is reed,cdresk here
Rev wwr 3anmry 9,2MG