Young, Dustin rrOUN OF QUEEVBU9Zy
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ^
`ame 5-)c) y oL) 1-4cy Case# Ct (�
Date Of Cremation l _nn Z
Time Cremation Started
Time Cremation Completed 0
Type of Container (:16,,C2 � /(/t,6A. �� '-10
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 td Cremate
The undersigned requests and Pine View Crematorium,in aocordance with and subject to its Rules and Regulations to
77M2�L_4_
(St) c ) (Stake) (zip Code)
who died , day Of �—
at
(Place) (Addresfi)
Name ands` In�r`Ir�g rive or rreina of person autlioSG2��/� --
(Name) % )
Relationship io the -
Name of Funeral Home ! -
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(hes no)pecenow,delbrill for or any other battery operated
device in his or her body. (Ckde One)
I certify that I have tug power and sue orb ation to arrange for the raemetion of the remains and to direct the disposition of the
cremated remains,that any personal Possessions have either been renmved or may be destroyed.and agree to prate defend and
save harmless Pine View Crenuftl im from any and al daints and demands for loss or damages which may be nre le ageirtst them
by reason d or connected with the d said as diracled,whether such dab. or demands are or are not wholly
7false gr
t 411 —r- ECG -- (Address)
(Signat�and/mess a Legal R )
Signed on this date: . / ____ _—.—
Disposition of Cremated Remains
I hereby Aer t Pine View Crematorium to CI R F ' of the cremated remair'rs os iblov=
Mail —
Othex arrarigerriertts-Please spedfy:
J i z 1_ p ll l -
If pulverization of cremated remains is requested,check here
Revision:January 1.2006