Pauze', Eugene 20T03� OF QUEE9�5BUTy
PINE SEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director Rc ,,t5
Fame [- i v----
v��fnc' ti�� e, Case# S� �
Dace Of Cremation
Time Cremation Started
Time Cremation Completed yU
Type of Container
Remarks C� SF
140 /,= ► b
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DEC-29-2006 03 :43 AM P. 02
Town of Qveensbury
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
crom lle the remains of:
A6 r vIZE:
(NombF (SOX)
date) (Zip Code)
(Street) � (City) ...-.. \..w/w! \-^r—___�
who died on - - day of 20Q.d
pieCe) (Address)
Name end address of nearest livinggrr�o►_otiva or name of person authorizing cremation:
� �-Y�.�'!G/S /`'mot.vt.�e. C/✓'. �tfO Ors ✓1
(Name) (Address)
Relationship to the deceased
Name of Funeral Home
IMPORTANT: nos no cempkor,dollbrillator or any other bauery operated
I represent that to the beet of my knowledge,tie decoa..ed(has) ( )
device In his or nor body. (Circle one)
I certify that 1 have full power and authorization to arrange for the cremation of the remains and to direct the disposllton of the
cremated remains.that any personal posmsslons have either been removed or may be destroyed,ww agree to protect,defend
we harmless Pine View Crematorium from any and all claims end demands for loss or damages which may be made against them
by reason of or eomvcted with the motion of sold remains as directed,whether such claims or demands are or are not whoDy
groundless,false or kjudulon
<
c
(Addre
i0 lure and s Relative or Legal Representallve)
Signed on this date: / ~ RI r
Disposition of Cremated Remains
I hereby direct Pine Vlow Crematorium to dispose of the cremated remains as follows:
Mau to
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
Revislom January 1,2006