Morehouse, Marilyn OF QUEEN5BUr�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director gtiKer'
dame �Gril Mare �ov�e Case# 3(�T
Date Of Cremation
Time Cremation Started_
Time Cremation Completed 11 0
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Type of Container �re7 C����, CASK ' SST
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
cremate the remains of:
V
inn • �'1�1.v�.c�y�w1`a� r-t�i`1fIZL'�
(Street) (City) (State) p Code)
who died on day of J 20-(-3 (a
at UdP ..�U7"L
(Place) ( )
Name and address of Wing relallve or name of crematlon:
(Name) (Address)
Relationship to the - — ^j — L
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tame of Funeral Home L uti
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)q (has no oemalcer,dalibrNOW 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,derend and
save harmless Pine View Cr+emetorkim from any and all Ge inns and derrsrds for loss or rip 1 gas which may be made against them
by reason of or connected with the cremation Lion of said remains as directed.whether such claims or demands are or are not wholly
groundless,false or fraudulent.
'
( and of Relative or Nepal Represent0ve)
Signed on this °a(Q
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
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Other arrangements-Please specify:
if pulverization of cremated remains is requested,check here
Revision:January 1.2006