Tatro, Keith 70 wN OF QUEEVBU-r�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEF.NSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director � �
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Case# 363
Date Of Cremation AU %Af 71
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Time Cremation Started
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Time Cremation Completed 'I
Type of Container a, ve ,,�w o
131
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 auttwizes Pine View Oematorium,In accordance with and subject to its Rules and Regulations to
cremate to a remains of:
1 TYl A I f ern �Q-�rC; /' olz-r
(Na ) ( >
�1/etu4"o�1` 0-BiC�/
'(Street) (City) r-- (Stale) (Zip Code)
who(;onace
Na and address of near living relative or name of person eulhorMrtg cremation:
(Name) O
Relationship to the deceased d 77/p--r
Name of Funeral Home B AYA/4V C 70/ t!Y Vnl
IMPORTANT:
I represent that to the best of my Ivrowledge,the deceased(has)or(has no)pacemaker,deflbriNator,battery,battery pack,power
cell,radioactive imply or radioactive device in his or her body.(Ckcle One)
I certify that I have full power and authoftetion to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,that any personal possessions have eNW been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View Crematorkxn from arty and all Anima and da rm for kiss or damages which may be made against them
by reason of or connected with the c errration of said remains as directed.whether such claim or demands are or are not wholly
Ise
(Will ) (Address) t� N /
(Signature and Address of Relative or Legal Representative)
Signed on this date: w 9 U S'T-I g-I v 07
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as foiknws
Mail to
Other arrangements-Please specify:
If pulvermadon of cremated remains Is requested,check here
Revision:April 18,2007