Hopkins, Jane TOUN OF QUEEVBU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director �. ,��
tiame 4o P K 1� S Case#
Date Of Cremation _ 2 Z' r Q
Time Cremation Started sr0
Time Cremation Completed 1 d
Type of Container <'14\;;zJ * 2d L L Ll
Remarks
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
creTole the remains of:
JAr A. F
(Name) (SOX)
z
(State) (Zip Code)
( ) (City) (J
who died onK yJ• +� Z�� day �—
at SH(Place)
- s
Na and,address of living relative,Q�r/ �1()� �� �me of
(Na (Address)
Relationship to the deo"
Name of Funeral Home
IMPORTANT:1 represent that to the best of my Iviowledge,the deceased(has)or(has no)pacemaker,defibrillator or any other battery operated
device in his or her body. (Circe One)
I certify that 1 have 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
l claims and demands for loss or
ges which
them
by treason ve harmless ine View Crematorium from any and connected with the cremation of said airemains direct whether such clad or demands are or are riot wh be made olly
groundless,false or fraudulent.
(Witness) (Address)
(Sig ure and Add Relative or Legal Representative)
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pin Vie
w ew Crematorium to dispose of the cremated remains as follows:
-Mail to Nt U
Other arrangements-Please specify: f�Rd Eb � ' AJ eAA,--
if pulverization of cremated remains is requested,check here
Revision:January 1,2006