Baird, Robert OF QUEEVBUr�y
PINE YIE`DY CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745.-4477
Funeral Director J'1, Ile,
Name �l o{yt-} 11�'r�` Case# 3�{$
Date Of Cremation 2oo-7
Time Cremation Started �; o
Time Cremation Completed f 10 ; Z0
Type of Container rc1
C 5—
Remarks
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211
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office: (518)745-4476,Crematorium: (518)745-4477
Authorizatlort to Cremate
The undue requests and authorizes Pm View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
gofiAZr V $i4lljp
(Name)
52 rA5?' 1441W ST IAIPrw 44A':e AN / 2gtiZ
(Street) (City) (State) (Zip Code)
who died on day of Au&t,5 r 20O-7
at G�fNS �S y 4Sj'rr ) G L s Fi+LLS, AY
(Place)
Name and address of nearest Wing relative or name of person autlwrt*ig cremation:
JaAIF— IiVRD SZ f AfA1,V ST, IAIPI ^� LASE_
(Name) (Address)
Relationship to the deceased w wit:
Name of Funeral Home MiL-sf FE�4L p{ONuE
IMrep esent that to the best of my ivrowledge,the deceased(has)or pacemaker,defibrillator or any other batttiry operated
device in his or her body- (Circle One)
i certify that I have full power and authorization to arrange for the cremation of the remains and to direct
t of the
end and
cremated remains,thet any pal p oris have either been removed or may be destroyed,mid all dalms and demeirids for loss or damages_may be_
serve harmlass Pine View reaso of �ciematlon tam of ofsaid rem directed,wheow such daims or demands are or are not whop
9� or fraudulent.
(Witness) (Address)
0J &--Z
(Signature and Address of Relattve or 69811 RepaesarftWe)
Signed on this date: --
Disposition of Cremated Remains
I hereby erect Pine View Crematonm to dispose of the cremated retry as f0P"&'&
Mail to
other arrangements-Please specify:-l� � i/J M/� r•
If pulverization of cremated remains is requested,check here
Revision:January 1,2006