Woehrmann, Ferdinand OF QUEEVBUr�y
PINE 'VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name err{ �c1 6J I, r Case#
s� rrrn ,nn
Date Of Cremation
Time Cremation Started
Time Cremation Completed_
Type of Container Occ -L l,a { ('r; jC"."o IS !Ft St
Remarks
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TO*4 (JIF 'QUEEN9gURY
PINE VIEW CEMETERY
a
CREMATOR I UM
Quaker Road, Quqensbury, New York 12804
Phone ;518) Crematorium � r no answer
matorium 745-4477 or
Cemetery 745-4476
AUTHORIZATION TO CREMATE
pinq View �.re*,storiuw, in
The undersigned requests and auhoriiesRules and Regulations to
accordance with and subject to its
cremate the raw*ins of'
-
(Name)
(City) (State(. (Z�;? Code)
(5trset) j
j lid a y o f S
wh a died Wo
o xy --- -�---
at l�OS U�l n�o ox%
(Place) (Address)
name of person
Name and address of nearest living relative or
authorizing crem`altionnt �� ?�
'LE I'll, n�J p N N .3�2 lit �7 Se u�'ro n1 c+-
(Name) (Address)
Relationship to the dece(a'sed
E y r /
Name of Funeral Home
dWp'2�- '�' -L�ly
IWORTANIT: knowledge, the deceased has or
I represent that to the best of my (Circle One)
has no pacemaker in his or her body.
I certify that I have the full power and authorization to arrange
for the cremation of the remains and to ersonaldapos►esseonsrect th shaveteitner
the cremated remainion Of
s, that any R
n removed or may be destroyed, and agree to protect, defend
been
save harmless Pine View Crematorium from any and all claims
and and demands for loss or damages which may be made against ties by
reason of or connected with the cremation of said remains as
not wholly
directed, whether such claims or demands are or are
groundless, false o�{r� fraudulent• fl,. t� �Ll
Ali"
ryl
fitness) (Address) ��� Uei„ � �, O
Po �
(S nature of Relative or Legal Rep. and Address)
Signed an this dater 11 11f1/'s/ '2