Van Horne, Norvan LO YV./ OF QUEE9�5BU�Ky
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director C,I<e
Name Jar F
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Date Of Cremation iz - 15 -O (C.
Time Cremation Started 1 ,: G AM
Time Cremation Completed 10 ' 00 4tl
Type of Container (CAf'c o.:, C: :FSt (/4SE
Remarks
DU (`'(
�o ly
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
cremate the remains of:
/V o 2 1119,61
(Name) (Sex) _
7U W , )
(Street) (City) (State) ( p Code)
who died on L day of / �'Al a���. 206 t p� (� ,�/
at-- � /"� /
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremati n:
��)c� / /r-cybZ Cis- L � ' '3 L E C,vZ. � 2�Y�
(Name) (Address)
Relationship to the deceased 4
Name of Funeral Home / L
IMPORTANT:
I represent that to the Best of my knowledge,the deceased(has)or(has no)pacemaker,defibrillator 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 Pi rew Crematorium from any and ail claitr►.s and demands for loss or damages which may be made against them
by reason of c nrgected with the cr ation of said remains as directed,whether such claims or demands are or are not wholly
groundless,false frau nt. v' (�f 13
M►ir-ess) (Ad ) �J
(Signature and Address of Re alive or Legal Rep r tative)
Signed n this date:
/3 !d
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