Planty, Alice T07IN of QUEEN,5BU-r�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUgENSgURY NEW YORK 12804
(518) 745-4476 (518) 745-4-477
Funeral Director Rclfer
Name��iCst �Iti�ty
Case# _565
Date Of Cremation
1 �
Time Cremation Started
Time Cremation Completed
� 6
Type of Container ���c�( 9
Remarks
v�lr_ 3d
�15 ;a Gil
CJL y; v l
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 undersvied requests and authoines Pine View CODFROWUM,in accordance with and aubjeot to its Rules and Regulations to
cremate the ins of: Pt4QA.�2- Fv
(Name) (-AX)
1(2--) 1\,C_t P 0 6 0.X e—t) '3 "�/' /
(Shaw) (city) (SU") (ap Code)
whodied on / day 46) ,
(Place) ( )
Name and address of relative or name cre
mation::
17
c 7-4,
(Nam)
Relatioriship to the deceased �—
Name of Funeral Home Itl / V,./
IMPORTANT:
I represent that to the best of my knawiedge,the deceased(has)or(has rho)paeernalcer,del brillstor or any other bar8ry apelated
device in his or her body. (Circe One)
I certify that I hove full power and authorization to arrange for the cremation of the remins and to direct the disposition of the .
cremated remdm.that any personal possessions have either been removed or may be destroyed,and spree to protect,defend and
same hominess Pine View Cnemokwk n f m any and so — and demands for ices or damages which may be made against them
by meson car vAh the cremation of avid v tolne as d`ire_cled,whelher such claims ordenm ere or are not wholy
C�13 / 2C-0 c�
(
(Sigrahire and of Relative or toga)Representative)
Signed on this dale: s—,
1.0!51
Disposition of Cremated Remains
I hereby direct Pine View Crernatorkxn to depose of the cremated remains as follows:
Mat to
Other arangements-Please specify:
If pulverizatlon of cremated remains is requested,check here
Revision:January 1,2006