Russell, Richard rrnWN OF QUEEVBU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director_ e -
Name_
Case#
Date Of Cremation 5- 3 — Ob
Time Cremation Started (a. 30 PM
Time Cremation Completed a: %4
Type of Container `�rcl�Jcr�
Remarks
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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 authorizes Pine View Crematorium,in accordance with and subjed to its Rules and Regulations to
cremate the remains of:
21L�� S^d 1\ kSse
(Nam) ( )
o�_ go7b
(Street) (City) ( )
who died on day of 200
at ) l �►�'
(Place) (Address)
Nmrhe Mc f nrwkrg relative or 0 Ig cremation:
(Name) (Add
Relationship to the decease/d� i
Name of Funeral home / 1 - . J /C�'L I—tJ,J
IMPORTANT:
I represent that to the hest of my knowledge,the deceased(has) (ha>nrloosmalter.deWillator or any other batlery operated
device in his or her body. (Circle One)
I certfy 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 dairrr3 and denrhencis for low or damages wtrich may be made against them
by reason of or connected wllh the oemedon of said remains ea direcEed,whether such claims or demands are or are not wholly
groundless,false or fraudulent.
(Address)
(Signature and Address of Retatkv or Legal Representative)
Signed on this date.
I
Disposition of Cremated Remains
1 hereby direct Pine View Crematorium to dispose of the cremated remains 85 follows.
Mail to
Other arrangements-Please specify:
if pulverization of cremated remains is requested,check here
Revision:January 1,2006