Saunders, George OF QUEE BU
PINE VIEW CEMETERY AND CREMATORIUM _y
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
C Funeral Director 15 rpr
Name nee* �,�sS
Case# _ �33
Date Of Cremation
Time Cremation Started b p
Time Cremation Completed tot Cu
Type of Container CI,-4, 64,, �('A !r)
lSi Cq. S�
Remarks
OCR AV o 'L(G c�
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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 s Awizes Pine View Crematorhxn,in accondarm with and aut>Jad to its Rules and Regulations to
the remains of:
(Name (Sect
�, t
Iq
(beet) (city) (State) Vpcode)
who died on day of__ sv ZO
(Piece) O
Name and address of nearest iivkg relative or name d Person
—7
(Nme) (Address) ZE t7
Relationship to the deceased EkL4t4at
Name of Funeral Home al
I represent that to the best d my latowledpe.the deceased ( alter,deQbrator or any other ba119ry operated
device in his or her body. (Cinde One)
i certify that 1 have full power and odwrtzatioo to arrange for the cremation of the ramairs and to direct the disposidw of the
cremated remains,that any personal possesslora have either been removed or MY be destroyed,and agree tD Protect,defend end
save harmless Pine View Clenm*xiun from arty and art chime and derrrands for low or damages which may be made against them
by f9mn wiIh the aemelion d eeid romeft sa df KV4 whedrer such chime order"da, ar+e or are not whole
grouridlem false or ftaudLderL
6 (Address)
and �)
signed on this dew � � 0
Disposition of Cremated Remains
I hereby direct Pine View Cmrrra*orun to dispose of the cremated remains as fdbws:
Meg to
Other errangements-Please specify.
If pulverization of cremated remains is requested.check here
Revision:January 1,2006