Coletti, Louis r-r
L O OF QUEEVBUPJ/-
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
/ ii Funeral Director_ �RKFtZ
Name v`�� 5 �csle i
Case# y!;
Date Of Cremation 10 -
Time Cremation Started t�� L16 PM
Time Cremation Completed
Type of Container 1n1c�a Ctrs' Cyr=,,,,,
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Remarks
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury,New York, 12804
Cemetery Office:(518)745-4476,Crematorium: (518)745-4477
Authorization to Cremate
The undersigned regkwsts and authorizes Pkhe View Crematorpxn,lh a000rd mw with and subject to Its Rees and Regulations to
cremate the remains of.
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(Streel) (City)
who died on /� day of t��T. 20-Q
(place) Qkddrws)
Name and address of nearest wing relative or name of person w*mizing cremation:
gnu is �o% r71
(Name) (A )
RelatorKt ip to the dec88Sed�e I�' PR P►�R2 A� c—
Name of Funeral Home
IMPORTANT: dedbrilleW or any other battery operated
I represerd that to the best of my latowledDa.In deceased(furs) no) emdaer.
devios In his or her body. (Clyde One)
1 oeNfy that 1 have fuN power end a NW&Ston to arrange for the aen►gWn of the remains and to direct the of the
cremated renldn,go any parsowl possesdons have either been removed or may be destroyed.and agree to protect,defend and
save trennim Pine View Cr+ernetorium forn any and all claims and demands for loss or damages whfsh may be made apanst tram
by vAh aemadOn of add Ferndna as dYec4e I vAretrer aw h dams or demands are or are not wholly
) ( )
( Address of or RepnesentaAhre)
Signed on this data: -
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated make as follows:
Mall to
Other arrangements-Please specify:
If pulverization of cremated remains is requested.check here
Revision:January 1,2DO6