Bullock, Jean Y
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PtNE YlEW CEMETERY �B C-1 �J
QUjA-4 .R RO�O, Q�r?NS8 ^� CREMATORIUM
(S18) 745.4-076 URY' K�W YORK 12804
(S18) 745..4-477
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Cremation Completed
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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 a ndergisned reds and maviaeg Pine View owattodum,in accordance with and subject to Its Rules and Regulations to
Cremate the remains of
(Name) (sex)
(Street) (City) _ ( ) (Zip Code)
who died on day of -� v I- 2o__!e
(Place) O
Name and address of nearest oft relative or name of person authat tg Cremation:
(Nam) O 7
Relatlonshtp to the decease�drbv�--
Name of Furav i Home
IMPORTANT:
I represent that to the best of my Wamedge,the deceased(has) (has no) .de�triNator,battery.battery pack.power
cell,radioactive implant or radioactm device In this or her body.(clidwow
I canny that I have fug power and auttutzgtlon to arrange for the cremation of the remains and to direct the disposil* of the
cremated remains,that any personal possessions have either been removed or may be destroyed.and agree to protect,defend and
save harmless Pine View Cremmarlum from arty and allicialms and demands for Joss or damages which may be made against totem
by reason connected ted with the cremation of said remains as directed,whetlter such claims or demands are or are not wholly
( )
(SWaaure and Address of Relative or Legal Representative)
Signed on this date: 7�SJ`07
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other anangemerss-Please specify:
If pulverization of Cremated remakls is requested,check here
Revision:April 18,2007