Ryther, Kathleen '7"Oq+N OF QUEEVBUr�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name `� qk�n �� � Case# 33S
Date Of Cremation
Time Cremation Started
Time Cremation Completed
Type of Container
Remarks
) btio �
r
33 �"
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 Pkhe View Crematodum.In accordance with and subject to Its Rules and Reguletiwta to
cremate the remains of.
e" ,/�/
(NamiD) (SOX)
/U 2-0 7- /9 lQ S&_j
O (cam) (Ste) wp )
who died on /S-' " L day of L3 20 6
at Qw ,J s 3 0///9'Z---
(Plow) O
Mama and address of wing retativs a creme of =aemetlon:
7
(Name) 0 (Address)
Reiatiorship to the deceased W'fL as
Name of Funeral Horne A. 1976&-Iq
IMPORTANT:
7
I represent tat to the best of any bnowledge,the deceased(has)Q-. ter hdcer;dells-n or any other ballery operated
device in his or her body. (Ckde One)
I certify that I have full power and to arrange for the crematlort of the r+ernako and to d rect the disposition of the
cremated remake.that any personel possesslons have either been removed or may be destroyed.and agree to protect,defend mid
save harmless Pkne View Crematorium from any and all ti I and "ll ; Illarlossork lgilwhidmaybe made egairnst them
by reason of or with the c romaton of add remake sit l o r-m d,whether ouch douse or demands ere or are not wholly
grouridless. or/
(Addre=
(SVvdur6flffl Address of Relative or Leo Represeruatl*
Signed on this deter 7 0
Disposition of Cremated Remains
I hereby direct Pine View Crematorhun to dispose of the cremated remake as follows:
Mall to
Other arrangemernts-Please spectly-
If pulverization of cremated remains Is requested,check here
Revision:January 1,2006