Beattie, Charles '71�l rm/N OF QUEEN,5BU,(�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
1 /� Funeral Director O t-d2enD"
dame_ l ��S C7� �! e
Case#.
Date Of Cremation ,, .%4 27 2001
Time Cremation Started T.20
Time Cremation Completed tb: t,a �M
Type of Container arcl � j. C r5T C S
Remarks
h,10j t , 30 AM MoV 4 1y �M
IQ�on
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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 Ruies and Regulations to
cremate the remains of:
K-ke,�-1es A K-a4,c Al
(Name) (sex)
(Street) (City) / (State) (zip Code)
who died on day of A"\ 20 G 7
at �� L� all r• ���� L_
(Place) (Address)
Nand address a nearest living relative�S m
of person authorizing creation:
(Name) (1 (Address)
Relationship to the deceased T�
Name of Funeral Home /r:/C�>�, r(✓
IMPORTANT:
I represent that to the hest a my iv�owledge,ilia deceased(has) has no)pacerr►akf derbriltator or any other battery operated
device In his or her body. (Circle One)
I cW*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 which may be made against mem
by reason of-or connected with the cremation of said remains as directed,whether such claims or demands are or are not wholty
ro fa udulent. --7
(witness (Address)
(Signature and Address of Relative 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