Planty, Francis 2r0cKN OF QU���821y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name F Ci j P1c,h� Case#
Date Of Cremation 3%j5AaL
Time Cremation Started A-H
Time Cremation Completed i( ' 3v 01
Type of Container (-k5l4'� �rquy'� � Sr CSS�
Remarks
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Cod 4Ov4 f I 6 A
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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
Authorization to Cremate
The undersigned requests and aut aizes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of
6,9
(Name) (Sex)
Y `7 �> y 1.7 r l - Gcd�r►�aS'ba"� !J y j�g �
(street) (City) (s1t;E ) (zip Coe)
who died on ?L 7 day of M A rG
(Place) —' ( )
Name and address of nearest living relative or name of person authoring cremation:
S'TA Iq p I�,s' Y,�7 P1AN7� 01,, LFe-147I~lb,y��'
(Name) (Address)
Relationship to the deceased P A" 1"n---
Name of Funeral Home lvl i1 A�c�i7 l3A Kt-,- Pale►-A I ke e—
IMPORTANT:
1 represent that to the best of my knowledge,the deceased(has)orIE30 pacemaker,defibrillator or any other battery operated
device in his or her body. (Circle One)
I certify that I have full power and authorization to arrange for the cremation of the remains and to direct the disposition of the
cremated remake,do 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 then"
by reason of or connected with the cremation of said remains as directed,whether such claims or demands are or are not wholly
groundless,false or fraudulent.
�'Yl�l�►a�8'. � Il �� �`Q��<--ter ;� ��`f
• (Signets and Address of Relative or t_egal Representative)
signed on this date: /M N r' ;- X7
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to depose of the cremated remains as follows:
Mail to
other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
Revision:January 1,2006
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