LaForest, James OF QUEEN,5BUr�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name 1kmp� ( e. FvrON&f- Case# 3� 1
Date Of Cremation - 12 —vim
Time Cremation Started
Time Cremation Completed_
Type of Container �j Cc,14 yA-d Cq
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, CremaWdum: (518)745-4477
Authorization to Cremate
The undersigned requests and autlwrmes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
creme the remains of:
(Name)
(Street) (City) (State) (ZIP )
who died on 5 - day of ' J 20 n'-�
(Place) ( )
Name and address of nearest living relative or name of person authorizing cremation:
O O
Raialionstrp to the deceased I'1 I -e L-'- - -
Name of Funeral Home M�1cr } �� r. = I 4-p ri ,
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has) (has no) .delibriNMor or any other beaery operated
device in his or her body. (Circle One)
I om*that I have KM power and authcrtzation to arrange for the cremation of the remains and to direct the deposition of the
cremated remains,that any personal possessions have either been removed or may be destroyed.and agree to protect.defend and
save harntiass Pine View Crematorium from any and 81 Cl I s and demands for loss or damages which may be made against them
by reason of or connected with the cremation of sold remains as directed.whether such dekns or demands are or are not wholly fI
5fWSeor I /
Address) ;CLY�„ Z
(Signature and/address of Relative or legal RepresarkatNe)
Signed on this date:
Disposition of Cremated Remains
I hereby iWact Pine View Crematorium to dispose of the cremated remains as foraws:
Mad to - - -- --
other arrangements-Please spedfY: _
If pulverization of cremated remains is requested,check here
Prevision:January 1.2006