Whiting, Frank Jr. TOrNN OF
QUEE9�(5Duj '�''
PLNE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745•-4477
J Funeral Director_
Name Fr fin': h },n ti J r
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Date Of Cremation
Time Cremation Started IZ +IG 17
Time Ctemation Completed 3;60
Type of Container CG�c Lad (r, ptiwtufCl
Remarks
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12804
Cernetery 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: , .
(Name) . (Sex)
1 Mi 0=56WT4 __-1 I - -- !?86+
(Street) ( ity) (State) (Zip Code) ,
who died on 4cur
p����``daay�o`f b� a �20 07y ,
(Place) (Address)
Na a and address of q�ea est living relative or name,of person autlxn�Irrg"cier lion:
W l�t I'4crlVl�Sa_fl'cU2P,n5�ur�, y
(Name (Address)
Relationship to the decee�aas//e��d���� w 1� ��,�����n,..^^ }�►�,p__ ____a_.,_,_,ff_
Name of Funeral Hom'lSAIVA 11+ l��I�t1r1N1 VtVI. U
IMPORTANT:
I represen that to the best of my knowledge,the decease ]or(has no)pacemaker,defitxillator or any other battery operated
device i hi or her body. (Circle One)
1 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 wholly
groundless,false or fraudulent.
(Witness) (Address)
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(Signature and Addr ss of Relative or Legal Representative)
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Signed on this date:
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Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:"aeraw -ro JR,tOU'�-NV kmE__
If pulverization of cremated remains is requested,check here _
Revision:January 1,2006
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