Bernier, Fleurette �O OF QUEEVBUr�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director �Qr► ��,(, �
Name �� F c 3e(In 't
Case#
Date Of Cremation 17-) A (-
Time Cremation Started 10 G �
Time Cremation Completed
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
a to the remains of:
(Name) (Sex)
(Street) (City) (State) (zip Code)
who died on S day of a 20 d
1 at ?� ` c
VT
(Place) (Add )
NaamIe--and address of nearest living relati a or name of person authorizing wlation:
2 ! 1_ ne—
(Na ( )
Relationship to the deceased
Name of Funeral Home /T 1 C��1 �^ r c �►Q ti �'��"r �-�-
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)orno)pacemak fi,de fttor 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 possesslons 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 roason of or with the cremation of said remains as directed,whether such claims or demands are or are not wildly
u or frauduWA
7 n ///� /}�' A.)
> (Adams)
X e ZAe
ignature and Address of Relative or Legal Represent
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose 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