Connelly, Mary Z'o of QUEEN,5BU-r�y
PINE 'VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(5 18) 745-4476 (518) 745-4477
Funeral Director l 4h
a t L o n ILl�ly t
Name ��
Case# _
Date Of Cremation 5 t 13 ZED 7
Time Cremation Started
9, ZD l�M
Time Cremation Completed 11: 3c,
Type of Container qrr POIJ G rgw�vdc1 15� C
SE
Remarks
MHrt eU AN MOVE 01110 /40
cool . !I 30 Atl
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•.
(Street) -'n- (City) (State) (Zip Code)
who died on ' `/•(/I day of �120
0-7
at 9b6713 TA ulw/ 6 kvA �i.
(place) j (Address)
Na and address of nearest living relative or neme$ferson
Na
(Nam ) (Adder)
Relationship to the deceased�! t"N Q .1 -
Name of Funeral Home L�
IMPORTANT: f
I represent that to the best of my knowledge,the deceased(has) (has no maker,defibrillator,battery,battery pads,power
cell,radloactive implant or radioactive device in his or her body.( )
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 arty and all claims and demands for loss or damages winch may be made against them
by r of or connected with the cremation of said remains as directed,whether such claims or demands are or are not wholly
grou false or fraudulent.
M� ) ( )
(Sig re and Address of Relative or Legal Representative)-
Signed on this date: !j _ 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 pulvertzation of cremated remains is requested,check here
Revision:April 18,2007