DeLarequera, Luis "'014N OF QUEEN
B 21
,r�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Directorh:
Name Case#
Date Of Cremation
Time Cremation Started
Time Cremation Completed 1, 1 fzi
Type of Container (rjw �I ���E
Remarks
Ll
c c i�
3b7
•y Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery give:(518)745-4476,Crematorium: (518)745-4477
Authorization to Cremate
The undersigned requests and authorizes Pine View CremsIodurn,in aocordance with and subject to its Rules and Regulations to
cremate the remains of:
Ode")
a M <N d le A21je-AYh9 lYd-6eAZ / , :3 21 J
(Street) I (CKY) (state) (Rip Code)
who died on 7 day Of�u c 20 r-b
at )b.4N (Address)
( )
Name and address of nearest Being relative or norm of person audwrbinp cremation:
�h oM�s 7)r✓l A l?e, e k 'SjNHe, #s fi
(Name) ( ( )
f�RekdWns to the decease/end uN l e' %� (�
Name of Funeral Home!"/ ,' )"d V °'�""GVl
IMPORTANT:
i represent that to the hest of my krmlAAedge.the deceased(has)oK rw pessn a m.delt Waln or any ad a baltory operated
device In his or her body. (Cirde One)
I codify that I have fill power and sidmWition to arrange for the cr+arration 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
sere harmless Pine View Crametorium faun any and al deans and demands for loss or damages which may be made them
by meson of or connected wllh the cremation of add or ob a as A P r 10 t1 Whorl er sudr dairrhs or derrmrtds are or are not w holly
grotavAess.Use or*aLKkAonL
`yn i
( ) (Andreas)
(14r
and Addnefss qf Relative or Legal Representative)
Signed on this dote
Disposition of Cremated Remains
I hereby direct Pine View CremaWrlom to dispose of the cremated rem as follows:
Mall to
other arrangements-Piesse specify..
If pulverization of cremated remains is requested,check here
Revision:January 1.2006