Orleman, Eleanor OF QUEEN5,BUTO,
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEL?NSHURY NEW YORK 12804
(518) 745-4476 (518) 745.-4477
Funeral Director 17/}J;
Fame
Dale Of Cremati.on
IN,' ,
C,; Z667
Tame Cremation Started q, C,,C, I
Time Cremation Completed I(U)"UCV
Tree of Container
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Remarks
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(DOO � (�
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury,New York, 12804
Cemetery Office:(518)745-4475, 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 _
(Street} (City) (State) (zip )
who died on l� /O., day of
__..._20'
at
(Place) (Address)
Name and address of nearest living relative or name of
` g- �O
-7
(Name) (Address)
Relationship to the deceased 1 Q lt '�
Name of Funeral Home fj'k t>ti� �y�
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or s no) def 1tator or any other battery operated
device in his or her body. (Circle one)
I certify that 1 have fuM power and authorization to arrange for the cremation of to remain and to direct the disposition of the
cremated remains.that any personal possessions have eMw been removed or may be desbaled,and agree to protect,defend and
save hanrrles's Pine View Qermftriwn fiom any and am claims and demands far loss or damages which may be made against them
by reason of or nected with the cremation of said r as drecled,whedw such darns or denrertds are or are not who®y
� .ra>se
�l
( d Address of Relative or Legal Representative)'
Signed on this date: , Z/23 !o 2
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Man to
other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
Revision:January 1,2006