Forth, Joseph OF QUEEN,5BU-r�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
II Funeral Director RgICpc
Name_ JOWL Fo'tl,
Case# 3f, f
Date Of Cremation
ZI Zo01
Time Cremation Started
: 2S �
Time Cremation Completed 3°•3u
Type of Container Oofb "V"F �g
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Remarks
IN 2: 35 P
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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 auttortws Pine View Crematorium,in accordance with and subject to Its Rules and Regulations to
cremate the remains of:
S os F0 tL i A-
(Name) (sex)
(street) (City) ( ) (ZJp Code)
who died on v day of T— 20Q7
(Place) (Addn
Na and address of living relative or name of person
aemadop---\�
J ll�t9.tiJ C� ��L�� JT �l`1✓L i �_C�'Uf7t'iYl,�
(Name) Aj ( )
Relationship to the dew 10
Name of Funeral Home
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,defibrillator,battery,battery pads,power
cell,radioactive implant or radioactive device in his or her body.(Ckrde One)
I certify that I have full power and aut orb ation to anarrpe for the cremation of the remains and to direct the disposition of the
cremated remains,that arry personal possessions have either been removed or may be destroyed.and agree to protect,defend and
save harmless Pine View Crematorium from arty and all daunts and demands for loss or damages which may be made against them
by reason of or connected with the cremation of said remains as directed.vAtetrter such claims or demands are or are not wholly
,false or
(Witness) U
/ 'T&Ce� � .
(signature and Address of Relative orLegal Representative)
Signed on this data. QJ/12 ,/
I
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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:April 18,2007
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