Liddle, Gordon �t
'7"OMN OF QUEEN,5BU�Ky
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUgENSgURY NEW YORK 12804
(518) 745-4476 (518) 745--4.477
Funeral Director ER
Name —ors(o+� � I (I
CI CI I C Case# ---�
a7
Dace Of Cremation 11- 36
1 i
Time Cremation Started
Time Cremation Completed
Type of Container CurA LA c,rC TEE,
Remarks
15 M
9 30 M
v -36
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 Crerrrate
The undersillned requests and auprorlms Pine View Ownataknb in a000rdence with and subject to Its Rules and Regulations to
cremate the remains of:
( ) (-Sex)
(Street) (City) (So") (ap Cole)
who died on -Z �7 L` day of OtJ�/7 a ZO�ZP
at A S
( ) )
Name and address of nearest eving relative or name of person awtrori¢irrg cremetlon:
Ce
O O
Relatior>step to the deceased s FJ M c P c r•S v 6/
Name of Funeral Worm
IMPORTANT:
I represent that to the best of my knowledge.the deceased(has)or n pocenrekar.deabriNator or any other battery operated
device In his or her body. (Ckde One)
I certify that I have full power and a awdzedw to arrange for the awnake of the remains and to direct the disposition of the
cremated remains,ttat any personal possesslons have either been removed or may be destroyed,and agree to protect defend and
save tamrlese Pine View Cremdorh=from any and all c l o l and derrards for loss or damages which maybe made against Own
by meson of or cornecfed wrh the cremadon of sold r0 wh as drscl4 w1w6w such cleirrs Or "I ors or are not vdx*
groundless,tatse or ftwxlulent.
N��� Acidness)
L
(Signattunure and Address of Relative a legal Repr+eserlr8ive)
Signed on this deter f 4-
Disposition of Cremated Remains
I hereby d1rect Pine View Crematorium to dbpo®e of the crenated remains as follows:
map to
other arrangements-Please spedfY-
If pulverization of cremated remains is requested.check here
Revision:January 1,2006