Conte, Rose TOWN OF QUEENSBURY
Pine View Cemetery and Crematorium
21 Qunker Road, Queenshury, NY. 12804.5902
(518) 74 5.44 76 (518) 745-4477
http://w-,vw.queensbury.net
Funeral Director: �- ?�Lk
Name of Deceased:
Case Number: Z ��
Date of Cremation: �'� 4-j
Retort:
Time Cremation Started: 10
Time Cremation Completed: �� II-AI
� , , 4
Type of Container: ,../�0�� �,J;J?,i /✓G'1�� � �v'!
Remarks:
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" Howe o NnttrraI Benuty ... A Good PInce 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:
(Name) (sex)
u mem 44- e"ruJ I L8�4
(Street) ity) (state) (Zip Code)
who died on (0 day of 2006
at & C,iflaeh Ave. Q1
(Place) (Address) '
Name and address of nearest living relative or name of person authorizing cremation:
?obart-C?onte. q P(rW-4j, Av-g— C eeat$four�,
(Name) (Address)
Relationship to they
Name of Funeral Home
IMPORTANT:
I represent that to the hest of my knowledge,the deceased(has)or s no)paoemake, brillator 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 t
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 not wholly
grou less,false or Wulent..
(Witness) ( )
(Signature
e(and Address of Relative or Legal Representative)
Signed on this date: ` — )I— 0(,
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here_![�—
Revision:January 1,2006