Garrett, Margaret �o�► �C OF QUEEVBUr�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director Re
Name ��n��, C rr`f11
Case# 335�
Date Of Cremation Li - - i.
Time Cremation Started
Time Cremation Completed
Type of Container 'd(, ',
Remarks
rt �✓ StG A
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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. /—
ell
' /'
( me) (Sex)
7 lcc(5on taus OY 283`I
(Street) (City) (State) (Zip Code)
who died on 0 day of 200
-WV at 0 //1Q t
(Place) (Address) ----- - _i— —
NaMe and add of nearest living relative or name person authorizing cremation:
(Name) ••,, (Address)
Relationship to the dec�ed 66 N
Name of Funeral Hom
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has) has no) aker,defibrillator or any other battery operated
device In his or her body. (Chris 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,defend and
save harmless PkwV1ew Crematorium from any and all claims and demands for loss or damages which may be made against them
by of orff'v4dw—
with the cremation of said remains as directed,whether such claims or demands are or are not wholly
gro ,
? za od
t )
(Sign a nd Address of Relative or Legal Representative)
Signed on this date: Z
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please spedfy: EM 1 u
If pulverization of cremated remains Is requested,check here
Revision:January 1,2006