O'Neill, John }
TO R"� OF QUEE9�50u!ky
PINE NqEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY NEW YORK 12804
(518) 745.4476 (518) 745-4.477
Funeral Director_ 3AKFQ
Fame TAB
Case# �
Date Of Cremation
Time Cremation Started
a /
Time Cremation Completed oG C
Type of Container g
Remarks
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9: 46
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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 authorizes Pine View Crematorium,in accordance with and staec:t to its Rules and Regulations to
cremate the remains of: II ll 311 10hW Q�N87LL d2t�
(am) (Sex)
33 0 094'j � . e . 1 2-1p-
(Street) (CM (State) Zip
who died on 3/ Sr day of 20
at
(Place) tom)
Name aM address of nearest living relative or name of person
(Name) (Address)
Relationship to the dew
Name of Funeral Home
IMPORTANT:
I represent that to the best of my Wwwledge,the deceased(has)or �nc�) .dallibrillator or any other battery operated
device in his or her body. (Circe 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 ether been removed or may be destroyed,and agree to protect,defend and
save harmless Pyre View Crentaeoritrm from any and aN claims and dernertds for loss or damages which may be made against them
by reason of wllh the cremation of said remains as directed,whetter such cleirns or demands are or are not wholly
V.-b jj
{Signattxe and Address or Legal )
Signed on this date:
o-,?--
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:Jerniery 1,2006