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Gazzille, Eleanor
r-rO OF QUEE PINE VIEW `��B U1'`J CEMETERY AND CREMATORIUM QUAKER ROAD, QijBgNSHURY, NEW YORK 12804 (518) 745.4,476 (518) 745•.4A77 Funeral Director Fame C i i' Case# pace Of Cremation — - ' me Cremation Started t me Cremation Completed � rpe of Container Remarks V V ©v� ti pis , M i° , qv Am �► L A11 ccu, I I I JoL 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 cremate the remains of: E LE owj e- (Name) (Sex) (Street) (City) (State) (Zip Code) who died on ILf 6 V?di tY, of G N 0 07 at -1 N 1)lAAJ elVek i?614 -B- E14-t.T r_C'�42e - `7v rFx,— (Place) (Address) Ce and ad ress of nearest living relative or name of person authorizing crem n: Q �lo{1�tsQr� 1� �r /l,�m-r e- 2 .4- l�� (Name) (Address) Relationship to the deceased,_ Name of Funeral Homo rrQ r)- //12,(L!A . '4'— IMPORTANT: I represent that to the best of my knowledge,the deceased(has) (leas no) cemaker,defibrillator or any other battery operated device in his or her body. (Circle One) I certify I have full power and authorization to arrange for the cremation of the remains and to direct the disposition of the crem r wins,that y personal possessbns have either been removed or may be destroyed,and agree to protect,defend and rbffreaf Pine V rematoriu from any and all claims and demands for loss a damages which may be made against them r con ellwith the rnat of said remains as directed,whether such claims or demands are or are not wholly se fr ulent. ( (Address) (Signature and A res of Relative or Legal Representative) Signed on this date: I 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 j I