Younger, John 2'o�v OF QUEEN,5BUP
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745•-4477
Funeral Director �/ ,��rC
dame_ U u�n ou�nti�lc
Case#. 3qL
Date Of Cremation S 200
Time Cremation Started AM
Time Cremation Completed
Type of Container
I5T C
Remarks
M TO 1
'0 ZuAm
0 0 17
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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
crema the remains of:
"A— 0Lk0 ci CA—
(Na (sex)
(Street) (City) (State) (Zip Code)
who died on � day of ._mac' _ 20 07
at Y P, A
(F ace) (Address) /
Name and address of nearest living relative or name of rson authorizing cremation:
-�
(Name) (Address)
Relationship to the deceased
Name of Funeral Home v,J rc 'te . L r7, e ,
IMPORTANT:
I represent that to the hest of my Iviowiedge,the deceased(has)or no)pacemaker defibdiator or
device in his or her body. (Chile One) any other battery operated
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 against them
by reason of or connected with the cremation of said remains as directed,whether such claims or demands are or are not w"fy
grour?'dI or ulent.
It (Address)
Va&pve-
(Sign re a e o(F the or Legal Representative)
Signed on this date: D A
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as fellows:
Mail to
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
Revision:January 1,2006