Hill, Gladys TOq+N OF QUEEVBUrR
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name C A Case#
Date Of Cremation I-
Time Cremation Started o fM
Time Cremation Completed ` bfJ p0�
Type of Container ���� SEA ^�� F-
Remarks
so
2 ,30
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:
(Na e) (Sex)
o z 12i Ole
(La
�8oq-
(Street) 0 (City) _ 1,• ' (State) (Zip Code)
who died on &!jg ,{ • q day of y�1�/ 20Q
at �. o Z dc�e �� G�e11S n�y
(Place) (Address)
Na nd address of rarest living rely or name pf person authorizing cremation:
(Name) y( (Address)
Relationship to the dace
Name of Funeral Home
IMPORTANT:
I represent that to the nest of my knowledge,the deceased(has or(has no)pacemaker. Iiator 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,defend and
se View Crematorium from any and all claims and demands for loss or damages which may be made against them
reason ed tirtlt��fer %lofaid remains as directed,whether such claims or demands are or are not wholly
ground ,false or ulent.
c�00,
( )
302- lens s. /J !ate/•
(Signature and Address of Relative or Legal Representative)
Signed on this date: A '
Disposition of Cremated Remains
1 hereby direct Pine View Crematorium to'dispose of the cremated remains as follows:
Mail to
Other arrangements-Plasse specify:ZE'iZt � Z1�L �bVK-Q
If pulverization of cremated remains is requested,check here t/
Revision:January 1,2006