Bovee, William OF UE� B Q ��s UTr
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745.-4477
Funeral Director--
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'_ Dace Of Cremation � q - G7
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T :me Cremation Started
Time Cremation Completed 10: ov
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Town of Queensbury
Pine View Cemetery and Grematorium
21 Quakes Road,Queensbury,New York. 128M
Cemetery office:(518)745-4476,Crematorium: (518)745-4477
A�to Cremate
The undersigned requests and autlwms Pine View CreftUMMIum>in accardwIce with and subject to its Rules and Regulations to
cremate the rem of:
Wi I w Ma ic, }
tik)n 5L C.nr 1 idh
(street) (CKY) (st>�ie) (Zip Code)
who died on c� of J 20_j(�7
at
(Place) )
Name and address of rare living reWw ar reams of person au*ortutg cremation:
i)JBz zJ i° Buz �
( ) h( )
Relationship to the deceased
Name of Funeral FIome hYea .t Y,f_ tit 1 1�f Q ►` �
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or aker,def y*ator or any other battery operated
device in his or her body. (Cfrde One)
I certtry that 1 have full power and authoftetion to arrange For the awnetion of the remains and to cu ect the disposition of the
cremated remains,heat any penwwW passawlam have either been removed or may be destroyed,and wree to protect defend and
save hanmiess Pine View Ctemeitx(urt!rota wW and aB chim and del wKb for loss or demeges which may be made a®*tst them
by reasonn afar eon eected wNh the cremation of said rteFnF I as dilredeck whether such dates or derrmnds are or are not whW
groundless.false or rraudulant.
(witness) (Address)
( e and�esm of Ralativ a or t eG&►it e)
r1`
Signed on this elate:_ I iM 1510 D
I
DispwAm of Cremated Remains
!hereby direct Pine View Cmamborium to dispose of the cremated remains as"ows:
Mail to
Other wmneem r-W Please specify: ni
if Pulverization of cremated remakes is requested,check here
Revision:January 1,2006