Rollerton, Philip OF QUEEN
B` - y
PINE VIEWCEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Na m e
Case#
Dace Of Cremation
Time Cremation Started [[
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Time Cremation Completed 0;3G AtI
Type of Container ��r� {� tl-.,�, C�
Remarks
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� G 066 11h
CddL i ° �30
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:
er yy
I n-1 h to 1�e 1)P r t Dais 1 r�Q)r_ —
(Name) (Sex)
G G y .S�rz c 1 C»s iU y
(Street) (City) (State) (Zip Code)
who died on ' ` day of c c 20 C$7
at G C !'b ?Lr CG
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
=Ccs.a R-211 hr'T>L%Fr-p
(Name) (Address)
Relationship to the deceased w i Fe
Name of Funeral Home Q
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her body.(Circle One)
I certify that I 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 reason of or connected with the crehation of saki remains as directed,whether such claims or demands are or are not wholly
groundless,false-or fra ulent.
(Witness (Address)
(Signature and ess of elative or Legal Representative)
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to f�- + - - — -A may)
Other arrangergents-Please specify:
If pulverization of cremated remains is requested,check here
Revision:April 18,2007