Dougher, Jon OF QUEENs5BU!�y
PINE VIEW CEMETE
CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director Br. 1—
Name T Or
°UGj k� Case# 340
Date Of Cremation
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Time Cremation Started
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Time Cremation Completed �'�2�
Type of Container l tir4bOar� rE_
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: ,
'JaA1 100 H� Mat_(Name) (Sex)
122 SUhngsldt: Nosh Qu QMbv. ,1 &U jZSW
(street (City) �— (state) (Zip Code)
who died on IQ day of 20E
at ook4.1'LD�-alu TTJSAI .0i�0()I Fc1 t S j n/`/ vn O 1
(fie) O
Name and address of nearest living relative or name of person audxxt ing cremation:
SOSac\
(Name) (Address)
Relationship to the deceased ,
Name of Funeral Home ��.�Q r�57 Yo
IMPORTANT.
I represent that to the best of my WxwAedge,the deceased(has)or(has no)pacemaker,defibrillator,battery,battery pack,power
can,radioactive implant or radioactive device In his or her body.(Circle Oche)
I ce*that I have AA power and authorization to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,that any personal possession have either been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View Crematorium from any and all dolma and demands for loss or damages which may be made against them
by reason o>a connected with the cremation of said remains as directed.whether such deims or demands are or are not wholly
c , ��.ylsh0 i z
(V ) (Address)
(signature and Adftft of Relative or Legal R ive)
Signed on this date: si /0
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 Pulver¢ dw of cremated remains is requested,check here
Revision:April 18,2007