Churchill, Joanne OF QUEEVBUr�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, Q11EENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
T �^ 1 Funeral Director 9ensmoa-<
Name Vo4.nd�,P l_ urt1���
Case# �S
Date Of Cremation Age Lst 74 100"7
Time Cremation Started ►Z;IS
Time Cremation Completed �-, 30 ?�
Type of Container Carr urc� �' w�, Isi rA [
Remarks
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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 Pine View Crematorium,In accordance with and subject to its Rules and Regulations to
cremate the remains of:
M„C
(Name) (Sex)
(Street) (City) (State) (zip Code)
who died on day of -k • _20 b.7
at L- }
(Place) (Addy )
NameAnd address of nearest living relative or name of person authorizJng cremation:
Ce e �D Lit aoa
(Na (Address)
Relationship to the deceased f
Name of Funeral Home s o;c ,,e
IMPORTANT:
I represent that to the best of my Ivtowledge,the deceased(has)or(has no)pacemaker,defibrillator or any other battery operated
device In his or her body. (Circie One)
I certify 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 harmless Pine View Crematorium from any and all claims and demands for loss or damages w k:h may be made against them
by reason of-or cortnected with the cremation of said remains as directed,whether such claims or demands are or are not wt"ty
groundiess fa lent. l — n r-�
five-
(mess) .
/z/L C , pX 7 72-/-Y-4--- - S
(Sign7ZL'�-
Address of Relat'ivre or Legal Representative)
Signed on this date: -
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