Griffing, Augustus F
OF QUEEN.5BUT,,y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QijEENSBURY, NEW YORK 12804
(5 18) 745-4476 (518) 745-4477
Funeral Director {
Name_
Case#, 3a%
Date Of Cremation s
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Time Cremation Started
Time Cremation Completed ( . �(i
Type of Container ( tird , Zc - S C
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 aocordance with and subject to its Rules and Regulations to
c�ema
erngs of..
ute the
urSli Ag 1,15
Name Sex
J) j M- V
(Street) (City) z
(zip Code)
who died on day of SIC i 20
at -o `r /�
(Piece) (Address)
f person
Name a�address of nearest civ' relative Of J ardhorizing creme � b�\ R '\ �/'
�R//+�vl`/ 4`/
(Name) (Addrreess) /
Relationship to the deceased �V
Name of Funeral dome
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or stlf�a no1lo��cemaker,defibrillator,battery,battery pads,power
cell,radioactive implant or radioactive device In his or her body.(Cirbb*r<
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 Crematortu from any and all claims and demands for lose or damages which may be made against them
of« ed with the of said remains as directed,whether such claims or demands are or are not wholly l ,
less,false« u t. �► �o�l,��fe�� A� f
(whvhess (Address)
(S' ature and Address-of Relative or Legal Representative) n
Signed on this date: + &
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¢ation of cremated remains is requested,check here
Revision:April 18,2007