Reich, Mark L orwN OF QUEEN,5BU-r�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name Mtirk I)etCL
Case#, 3
Date 0f Cremation S 10
17,501
Time Cremation Started
Time Cremation Completed
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Type of Container �� j ; U.
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 audwrtms Pine View Crematorium,In accordance with and subject to its Rules and ReWlstions to
cremate the remains of:
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(Name) 119 ( t'� l G / 2-
(Street) (city) ( (Z
ip Cam)
day of _ 20_
who died on _
at b w
(Address)
(Place) /
Name and address of nearest living relative name of person authorizing aemstim: /
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(Name) ( ) Cil?ti� �
S vL-_- _.
Relationship to the deceased
Name of Funeral Home �L 15�7���� �t2,�1(L ✓? /
IMPORTANT: 'n or,battery,battery pack,power
I represent that to the best of my ivwwledge,the deceased(has)
cell,radioactive implant or radioactive device in his or her body.(C
kdFUW
I certify that I have full power and andhorizedon to arrange for the cremation of the Term"and 1D direct the disposition of the
cremated remains.that any Persooai P have anther been removed or may be destroyed,and agree to protect,defend and
save hamdess Pine View Crematorium iron any and as cities and demands for loss or demages which may be made against them
lmandAdRl
connectedation of said remains as dhreW4 wint her such ohs or derrarKa are or are not wholly
(Address)
of Relative or Legal Representative)
II
Signed on this date: 1 9 O
Disposition of Crenated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains 89 know-
Mail to
Other arrangements-Please W8CdY
If pulverization of cremated remains is requested,check here
Revision:April 18,2007
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