Schuckle, Albert T0T�N OF QUEE BU
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Famek LQ
Case#
Da t e Of Cremation Ob
Time Cremation Started
w, 3c, PM
Time Cremation Completed II' io PM
Type of Container C4rC(►7Oc•< 1F = If //A
Remarks
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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 accordance with and subject to its Rules and Regulations to
cremat the remains of:
b o
(N10A
e) (Sex .,�"�
2 � _____ �y._ 1 �t
(Street) (City) (Slatd) (Zip Code)
who died on day of_ l b�'----- - 20610
at (Place) �� (Address) GieAS
AddressAS
Namq ar►d add ess of nearest living relative or name of pe�rs9n authorizi remaUon:
�e 5 e_2 Kkow- QLAt�4(4t�- -M
(Name) (Address)
Relationship to the d WI
Name of Funeral Home
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)��xmceaker,defitxillator or any other battery operated
device in his or her body. (Circle One)
I certify that 1 have full power and authorization to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,that any personal possessions have either been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View Crematorium from any and all claims and demands for loss or damages which may be made against them
by rea f or connected with the cremat' remains as directed,whether such claims or demands are or are not wholly
gro dle ,false or fraud
(Witness). / (Add ess)
fi ' �_C _
(S' ature and Addr a era rve or Legal Representative)
Signed on this date: 2 13
10,
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