Whipple, Marjorie �o�► �C OF QUEEVBU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director l)�,�er
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Name I`1Gt- ,;1,� e Case# 'S;j �
Date Of Cremation
Time Cremation Started
Time Cremation Completed
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Type of Container CS��(6�. ;� r n (`SV+
Remarks
M C; J �� �n
31;7
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Offim:(518)745-4476,Crematorium:(518)745-4477
Authorization to Cremate
The wxwsigned rewe is and autortaes pke view Cmna�orfum.In aooerdarroe aubl d to ks Rules and Regulations to
cmnate the remains of:
(Nome) (Sex)
(street) (Uty) f (State)who died on t _ day of G (j 1 ZO tP
at l C [[� 1 � -S S F'
(place) (Add)
and eddna''ss/I Of rleara6t liVlrlg lelaliv8 name Of atolorltiv aemeban•
O )
Reiaiorrship to the deceased r C��`-JO Nam of Funeral Hoare f `� r U tJIG
IMPORTANT: the deceased(has) (ha�np .dedbrillaw or any other baftY operated
1 represerx tlmt to the best of my bwwledge,
device In his or her body. (Cirde One)
I oa*that I have fill power and authorization to artange for the awnedo►of the nernairm and to direct die disposition of dw
cremated remains,that any personal posessalom have eidter been removed or may be desboyed,and agree to protea defend and
save tmndm-Pkn View Cn na lorium from arty and all dams and dertrards for lose or damages which may be made against them
by reason carmected vAh the cremation of add renretrrs as d A I N J,tNreUrer �
such deb Por dairmid�s are or are not wholly
KSKIMS, or
of Reletive cr t egaf Represert�hre)
( lv r .
Signed on Ws dele:
Disposition of Cremated Remavrs
I hereby direct ph*view CMffWtWM to dish of dye cremated remains as follows:
Meg to
od,er arrangerne o-Please specify:
If pulverization of cremated remains is requested,check here
Revision:January 1,21M