Locke, Joan �O OUE�
2 N,SBU
PINE VIEW CEMETERY AN
D CREMATORIUM
QUAKER ROAD,
QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director I`�
,Fame � I � _
j oq n
C a s e# Say
Date Of Cremation
Time Cremation Started
15
Time Cremation Completed ti : 3
G
Type of Container TE
Remarks
T
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� 30
8' SO
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office:(518)745- 476,Crematorium: (518)745-4477
Authorization to Cremate
The undersigned requests and author¢es Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remqrn of:
Xf/tz
(Street) (City) n�,t (State (Zip Code)
who died on :l day of
f
at (Place) (Address)
Name and address of newest relative or name of person authormng
(Name c )
Rekdlorship to the
Name of Fuuneral ( `
IMPORTANT: �) ,defbnNator or any other Y operated
I represent that:to the best of my krwwledge,the deceased(has)
device in his or her body. (Cirde One)
I cw*that i have full power and aulhorb ation to arrange for the crerrcadw of the remains and to direct the disposition of the
cremated remains,emd any personal possessions have either been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View Cre�orhxn from any and all daims and demands for loss or damages which may be made againsttl�ern
by reason of or connected with the cremation of sold resin as directed,whether such daims or demands are or are not wholly
less,false or fraudulent.
J Zhdof
(address)
eelative or t_egal Represer►tative)
Signed on th data: -
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispoee of the cremated mmam as follows
Mai to
O*W wTangaments-Please specify:
if pr&Otwdon of cremated remains is requested,check here
Revue jarnmry 1,2000