Dubret, Louis T01j+N OF QUEE BUP,,_y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 3q �—
Name Lu�� S I� ,��..�
Case#
Date Of Cremation --0�
Time Cremation Started 7. .�1C
Time Cremation Completed IU;OCj
Type of Container ` �,ICi�(rrJ
Remarks
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Of iioe:(518)745-4476,Crematorium: (518)745-4477
The undersigned requests and authorizes Pine View Cremnatorhnn,in accordance with and aubjW to its Rues and Rieguletions to
cremate"remains of.
Ln U IS 1Z L ,( _��
(Name)
( )
city) 4 ) (aP Lev Z y
who died on day of 20�
at
(Place) ( )
Name and address of living relative or named person
O
Relationship to the deceased
of Funeral ome
Name neral H
`z
IMPORTANT: de�r�leAor or arty other battery operated
I represent that to the best d my tanowtedge,the deceased(h pao
(has)or(has no) ernaker,
device in his or her body. (Cirde One)
I certify diet I have full power and ardhorirstion to arrange for the cremation of the remains and to direct the diaposition of the
cremated remains.that arry personal possession have either been removed or may be destroyed.and agree to protect,defend and
safe againstithern
byfewhemrteas View i<e �re m dUeclad,wh all ran' andrin I y� ar dernagesvAilch �be
wholly
groundless, a
(Sign=/ &
tregW Repreeentative)
Signed on this data
Disposition Of cremated Remains
I hereby direct Pine View Cremewdurn to dispose Of the cremated remains as fOhowS:
Mae to
Other errangements-Please specfT.
if pulverization of cremated remains Is requested,check here
Revision:January 1,2DO6