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Skiff, Lois OF QUEE9�f,5(BUr� PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745.4476 (518) 745.4477 Funeral Director Fame - Case� jj� .aye 0 ( Cremati.on Time Cremation Started AN Cremation Completed (� 3 Tree 01 Container Remarks q - 410 40 n -^ M °UL 13 U A Town of Queue► Pine View Cemetery and Crematorium 21 Quaker Road,Queensiwry,New York, 12804 Cemetery Office:(518)745-4476,Crematorium: (518)745-4477 Authorization to Cremate The urWersi fined requests and aug orimes Pine View Ourakwmm,in accordance with and subted to its Rules and Regulations to cremate".remains of: t o i S g. � iC )t=r I`r✓ Oz (NM* (�I revs �fi7ur �� ^ /2 Y'-- (street) (C.ky) (Sbft) co" who ulieci on day Of of c I,i- 2D_.! at_ GJ ` Yi2 ' Y (Place) U ` Name and address of 1 WAv rotative or creme of person sudwrb fng crenretiorr: � I ( ) ( ) Rip to the d ed ,^F2 c M i ov ©ICd✓1 ,6 Name of Funeral Borne A /► g tom(e"L Fy�j iL l l7. MPORTANT: i represent that to the best of my kamedge.the deceased(has)or(has no)peoretuakar.defrillstor or any otter bo"operaled device in his or her body. (Came One) I certify that t have fLA power and autleorbMan to arrange forow en m Son of the remains and to I a cl the dfesposiion of the aematad remains.than any persoaet poaseedorrs heue aittssr bean wmoaed or may be desbv ad.and agree>Q protect.defend and save trameiess Ptn vier.c mwo anon tnmr any and ail claims era deeubnds forbM or dengyees.rticn raray be wrede aaeirrst ttrerrr by reason of a wih fire aeme6orr of said 4 whuefrer such cieime or demands are or are not whoy gr>trrdless. �zea y ( a�-w of Relative or legal Representatift) Signed on this date DWDSMW of Cronaled Remains i hereby direct Pine View Cr+ermw&m to dispose of the cremated rernains'as folimm Mato Other arrangements-Pleee sped(y: if pulverization of cremated remains is requested.dredt hem l�evis�on;J ac►ua,r� ��20�b