White, Jill T'07tiN OF UEE
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PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY NEW YORK 12804
(518) 745-4476 (518) 745.4477
Funeral Director_ ,
mor
Fame e
Case#
Date Of Cremation
Time Cremation Started
Time Cremation Completed 16
Type of Container
Tt
Remarks
LL
Cook i w, Mn
' b 5
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
cremat the ins of:
U(Name) (Sex)
(Street) (City) ,(�' (State) (Zip Code)
who died day of i/—� 20!p�
at
(Place) I I (Address)
Name ang address of nearest living relative or name of person aauthorizing cremation:
LYE E G�-�G
(Name) (Address)
Relationship to the deceased
�
Name of Funeral Home
IMPORTANT:
I represent that to the bast of my Iviowledge,the deceased(has)or(has no)pacemaker,defibrillator or any other battery operated
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 cremation of said remains as directed,whether such claims or demands are or are not wholty
gr ndless,false or trau0ent.
Pitnegs1 t (Address)
1 - f
1V (S n ure iraAWress of Relative or Legal Representative)
Sign"this date: J IYA
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:January 1,2006