Davis, Kara �o OF QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director �, g0r �
Name -C, ��v15 Case#
Date Of Cremation /4 ( G
Time Cremation Started !� ;
Time Cremation Completed J "u
Type of Container
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 subject to its Rules and Regulations to
cr jze the remains of:
(Name) (Sex)
711 sz. Q-6 1`m
(Street) (City) U (State) (Zip Code)
who died on day of Mci 20 Ka
at_ Lt`f
(Place) (Address)
N and address of nearest living relative or name of person authorizi cremation:
L al r M
(Name) (Address)
Relationship to the deceased M ti,e
Name of Funeral Home r L °^^ `—
IMPORTANT:
I represent that to the best of my Mowledge,the deceased(has) (has no)pacemaker fibrillator or arty 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 pQssessi"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 claims or demands are or are not wholly,
g e�rfreudu t. 7 S4erM.K O-1IK—'
(Address)
(Signature,a/ndd Address of Relative or Legal Representative)
Signed on this date: I t
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as fdlows:
Mail to
Other arrangements-Please specify:
If pulvert ration of cremated remains Is requested,check here
Revision:January 1,2006