Howe, Cranston ' " rmlN OF QUEEN,5BUr�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENggURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director_Ro���
Name �fgnS G
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Date Of Cremation
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Time Cremation Started
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Time Cremation Completed :oo Pt
Type of Container a�
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Remarks
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Town of Queensbury
Piste View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12804
Cemetery Office: (518) 745-4476,Crematorium: (518)745-4477
Authorization to Cremate
The undecsgned requests and authorizes Pine View Crematorium,In accordance with and subject to its Rules and Regulations to
cremate the remains of:
(Name) (sex)
(Street) (City) to e) (21p Code)
who died on /J day of_,43'Lt� kS� Z0
at� ' t; r s�' � � e.J
(Ptace) (A"ess)
Name and address of nearest livfng rma ve or name of person aulhcrVJng cremation:
�✓ S
(Name) (Addrw-s)
Relationship to the deceased
Name of Funeral Nome_! ✓` /
IMPORTANT;
I represent that to the hest of my knowledge,the deceased(has)oErto>MernaKer,defibrillator or any other battery operated
device in his or her body. (Circle One)
I Certify that I have full power and author nation 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 them
by reason of or Connected with the a ion of id remains as directed,whethef such claims or demands are or are not wholly
groomfalse or fra lent.
(Address)
( nature and reps of Relative or Legal Representative)
Signed on this date; A!j&I S �Qv "
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Disposltlon of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
- I
Other arrangements-Please specify'
If pulveriz3bQn or cremated remains is requested,chock here
Revision:January 1,2006 j