DeBarbieri, George OF 1r1.L L
2 NSB Ury
PINE 'VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name
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�e CIO erg Case# 3�
Date Of Cremation
Time Cremation Started
Time Cremation Completed
Type of Container
�ND
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 authorizes Pine view Crematorium,In accordance with and subject to its Rules and Regulations to
cremate the remains of..
Cleo,.-S4r, �7'h - 7CG�,�b;�Y _- rnJt
(Na (Sex)
) s u) 5C,,F rv5�
(Street) (City) (State) (Zip Code)
who died on g 16)67 day of Yr7 o n h — 20_C7
at 5F• -
(Place) ( >
Name and address of nearest living relative tto
or name of person au rtZing cremation:
L
(Name) (Address)
Relationship to the deceased V,-'> c
Name of Funeral Home
IMPORTANT:
I represent that to the best of my ivtowiedge,the deceased(has)or no) aker,defibrillator,battery,battery pack,Power
lant
cell,radioactive imp or radioactive device in his or her body.(C'
I certify 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 agate them
by reason of or connected with the of said remains as directed,whether such claims or demands are or are riot wholly
groundless,false or fraudu
77
( )
/ i
(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 2,44 s,-, -An E.'U
other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
Revision:April 18,2007