Clute, Charles 0F QUEE BUr�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral DirectorVte
Case#
Dace Of Cremation
Time Cremation Started I * Pt
Time Cremation Completed
Type of Container ecvaerj lrft
Remarks
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J lJL-t�3-1 bk16 06 :50 AM Lut i k:wano. LLC 703 738 6829 P. 21
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury,Now York, 12804
Cemetery Office:(518)745-4476,Crematorium:(518)745-4477
Authorfzatlon to Cremate
The undersipried+aQwoft and evywrim Ph*VW*Cremarorlum,in eeear*rvs w0 and to Its RUN ars3 Reputedone to
cnsrriete tns owna`kre oh
(Cky) te6s} IMP�Codsf
who died on a 6 day of ---- — �0—
Name end eddrssa o,na WW vving f WW*or memo of parson aNhO*rg cremstion,
(Name) (Addt ees)
Reboa>etiip to the deceased
Nsrne of Funorsl Home
IMPORTANT:
I mprueent that to the beet of my lwowfedpe,the decesced(has) ro pecemakct,dtrrlbrwetor ixany o0w battery aPerated
device hn hle or her body. (C"Urns)
i c ert+fy that 1 have full power end authornspo to a eh mgdw ofor may beldeetroyad.&w to gme pr�xect deMxt end
cremator rbm pb thal any WrA0 el possess��sN claims mid dMnends to Im or demepse~►W be made apektct tnem
save hermrlass Pine Yisw CrerlreRariurn fiiom arty
by reoeon of or Connected whh the cremation of esid remeine es directed,whether each debm or Jsmsrtds me or we mot wholly
gnsets) (1►mm")
- (Signature and AoM Rstetive a lepat Repmentative)
Signed on this date:-.- . ,V"—.�-2 .,
Dispoeidon or Cremated Renwins
i hereby direst mite View o vmetorlum to dispose of the cram o*d rerreins sa idiaq:
Mail to
OtW errsrgements•Dlesssif pulverization 01 crgff*dd WnSM to M**S ed,deck here ..
Revision-January 1.2006