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Smith, William
TOWN OF QUEENSBURY Pine View Cemetery and Crematorium 21 Qunker Road, Queensbury, NY. 12804.5902 (518) 745.4476 (518) 74 5.44 77 http://ww\v.quccnsbury.net Funeral Director: '�tit�� Name of Deceased: W 111►a� 5m 1+� Case Number: I L Date of Cremation: 3 l b Retort: rc,w�vr el �St 6 't Time Cremation Started: `j ` �' A t H . Time Cremation Completed: Type of Container: (. ti rd b o a r I Remarks: m�►h q : tb AM �►,©�c q = so HM pc' ; V5 AM ill I � AM j AM . I Honte of Natural 8enuty ... A Good Plnce to Live " 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 cremate the remains of, I6311-�-1AM R �rno-� tl A,L.E (Name) (Sex) _lo�C 'ScAul LEtz ::�T, . LAkE GsoRc,E,�fl&.'D!AARV' lav's' (Street) OT(City) (State) a (Zip Code) who died on 04 day of `YY\R 2Lkk 2O�. at C LIS, SPj-i L. I00 PA R1Z (Place) (Address) Name and address of nearest living relative or name of person authorizing cremation: i_ E a (o 30 ( ) ( ess) Relationship to the deceased Name of Funeral Home IMPORTANT: I represent that to the best of my knowledge,the deceased(has)or(has no)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 remains,that 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 them by reason of or connected with the cremation of said remains as directed,whether such claims or demands are or are riot wholly groundless,false or fraudulent- tv'�n;:C- 0-1&30 ' 69 1�ILALAe.3O AVE. , E.mF(2Sat��11�` C)To30 (Signature and Address of Relative or Legal Represen ive) Signed on this date: f�-CAk rl A O 000 Disposition of Cremated Remains I hereby Bred Pine View Crematorium to dispose of the cremated remains as follows: Mail to Other arangements-Please specify: If pulverization of cremated remains is requested,check here Revision:January 1,2006