Blood, Patricia OFQUEE9�SoUp,�,
PINE VIEW CEMETERY AND CREMATORIUM
QUA-ER ROAD, QUELNSBURY NEW YORK 12804
(518) 745-4476 (518) 745'-4.477
11 Funeral Director_�j�K[�
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Case# �
Date Of Cremation
me Cremation Started
? , me Cremation Completed ICi
'yPe of Container
Remarks
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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
Au#KHiZBUW to Cremate
The mimsigned requests and attho bW Rine view Cmmtork m,in accordance with and&Abject to its Rt*m and Regulations to
cxernate ins of.
C-
(Nam) (Sax)
A).;Fl a
O (city) (SUM) Rho )
who died on 1 day of E Y- c�
r / or
(Place) O
Name address of �relative or name of cmnalion:
( ) (Addne�
S -
Relatior>ship to the deceased _
Name of Funeral Itiome —
IMPORTANT:
I represent that to the best of my IatowlediA the deceased(has)or s 7�nq) .def illalor or any otter betty operated
device In his or her body. (Ckde One)
I certify that I hence full power and att<hori mom to&wre W for the cremation of the nwraka and to direct the won of the
cremated mffak s,that any personal posseslons have either been removed or may be destroyed,and agree to protect,defend and
save tarrrhle&s Pine view Crernetarhum from arty and al cleans and dennhards for loss or damages which may be made agate them
by fe8Wlr&oraxmecIgdwkh the awn egon of acid renhekhs as directed.whether such All or dernend&are or are not wholly
)
kvW ��--
( nd a Addrew of Relative or Reps e)
Signed on this dace: j /2-/()7
Disposition of Cremated Remains
i hereby erect Pka view CterrnaWm to dispose of the creoaied remains as"lows:
Mat to
Other artahgemerns-Please specify:
if pulverization of cremated remains Is requested.check here
Revision:January 1,WN