Hlavaty, Gloria Qu E UT�
PLNE VIEW CEMETERY AND CREMATORIUM
QU/`Kp�t ROAD, QUERNSBVRY, NEW YOR}C 12804
(518) 745.4-476 (518) 745.4477
Funeral Director
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Casey
Cremation
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^e Cremation Completed 30
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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
Authorization to Cremate
The undersigned requests and authorizes Fine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
��oRiir��i✓AN TY �ertgl�
(gym) (Sex)
15 9S$A (City) (State) (Zip )
(Street)
who died on .TG(N A5 d day of _--_ 2o 0'7
at 101"- IS )4c2stpl-f4 T 10Z 19/bli.i<; c�� NS /J S /•�'U�
(Place) (Addres—)
New arid address of neerest oft relative or name of person authorizing cremation:
l(Name) ItTJ (Address)
Relationship to the deceassed&d��" Ste" �
Name of Funeral Home 1 1 fZ N Al A(l� ��19 K�2 ! Gl/V / Akwe
IMPORTANT: the deceased(Ices) (has ra oemeloer,doNxi bior or any other battery operated
I telhreserrt that b the best of my Ivhowledge,
device in his or her body. (Circle One)
I car*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 henniess Pine View Cramiftrium from any and all dalms and demands for loss or damages wt*:h my be made against them
by reason or carrrtected with the a nredw of said remains as directed.ted.vrhWW such claims or demands are or are not wholly
or
CV yB d 7' e Y iJ
(wnr>�s O
(Signature and Address of Relive or �)
Signed on this data. Nov, 15, 06
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Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mall to
Other arrangements-Please specify:
If pulverization of cremated remains Is requested,check here
Revision:January 1,2006 j