Mosher, Helen T07+N OF QUEEN,5BUPJ/-
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12844
(518) 745-4476 (518) 745-4477
Funeral Director )�
_ V A R t)1"';,f C
Name He (en Masi,; r
Case# _ 1-((, �
Dace Of Cremation 10 — C L
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Time Cremation Started 1c 6
All
Time Cremation Completed 3a
an
Type of Container ""4 LOrel �G'E tST CASE
Remarks
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Su �y
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 requests and authorizes Pine View Crematorium,in aocordanoe with and subject to its Rules and Regulations to
cremate the remains of:
H ewv\ el
(Name) (Sex)
7 Hle-ok
(Street) (City) (State) (Zip Code)
/
who di �(-4-ed on U n/1 day of 1-1� 20
(P ) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
(Flame) (Address)
Relationship to the deceased
s _
Name of Funeral Horne,f � s ^� r �u�►t r. a'-�, �, 1��
IMPORTANT:
I represent that to the hest of my knowledge,the deceased(has) (has no)pacemak ,defibrillator or any other battery operated
device in his or her body. (Circle One)
I certify that I have full power and authorization to arrange for the Cremation of the remains and to direct the disposition of the
ns
cremated remains,that any personal possessio have eithWbeen removed or may be destroyed,and agree to protect,defend and
save harmless Pine View Crematorium from any and all daims and demands for loss or damages whiclt may be made against them
by reason of or connected with the aemation of said remains as directed,whether such claims or demands are or are not wholly
7fa fraudulent.
(Witness) I
(Address) i
(Signatures and Address of Relative or Leg61 Representative)
Signed on this date: C� CA `
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
Revision:January 1,2006