Squires, Lena L O( VN OF QU-EEVBUir�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director_ /4lCya^c�c,r,
Name ���nc� 5 c, ors � .
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Date Of Cremation is _ Q' — o(o
Time Cremation Started 5`10 A M
Time Cremation Completed Q "()G +'M
Type of Container Cws�eT 61ci-JeJ rs
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Remarks
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TOWN OF DUEENSBURY
PINE VIEW CEMETERY
a
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHORIZATION TO CREMATE
Thie undersigned requests and authorizes Pine View Crematorium, In
i' accordance with and subjece to its Rules and Regulations to
cremate the remains of :
(Name) (Sex)
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I (Street ) (City) (State ) ( Zip Code )
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who died on ?i day of ;A�G
(Place) (Address)
'' Name and address of nearest living relative or nave of person
authorizing cremation :
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(Name ) (Address)
Rellationship to the deceased S��✓
' 1 Name of Funeral Home
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IMPORTANT:
ILr resent that to the best of my knowledge, the deceased has or
( s n pacemaker in his or her body. (Circle One)
. I Icertify that I have the full power and authorization to arrange
! for the cremation of the remains and to direct the disposition of
j the cremated remains, that any personal possessions have either
' been removed or may be destroyed, and agree to protect , defend
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and save harmless Pine View Crematorium from any and all claims
and demands for loss or damages which may be mane against them by
reason of or connected with the cremation of said remains as
directed, whether such claims or demands are or are not wholly
undless, fa se or fraudulent .
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(W ' ess ) (Address )
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(Signature of Re ative or Legal Rep. and Address)
Signed on this date : 7-I�