Cypler, Kenneth III OF QUEENB 1.1
r�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QLlEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director t�: I�
Case# _ 1�Z7
Date Of Cremation Uct"lht
1 r
Time Cremation Started iy V�J
Time Cremation Completed CU00 �M
Type of Container (,�r�bmrar.
Remarks
� v
-------------
Town of Queensbury ZI
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
crenVKe the(remains of: _
A� eFe A1,pr 111—
(Name) (Sex)
G SIATrneY« PArl( - S "0X) gg- N • Cp
(meet)—� (City) .....
(State) (Zip Code)
who died on Ilk, �e i day of Q C G O — 20at
(Place) (Address)
Name and address of nearest living relative or name of person udxxtzkV cremation:
le liP• �r-OOn� !�Nl` N / 7-
(Name) (Address)
Relationship to the deceased l `
Name of Funeral Home
�-l .
IMPORTANT: the deceased(has)or( no) maker,defibrillator,battery,battery pack,power
I represent that to the best of my ivtowledge,
cell,radioactive implant or radioactive device In his or her body.(Cir
I certify that I have full power and authorization to arrange for the cremation of the remains and to d Wee t prodisposition ,defend and
cremated remains,that any personal possesand
sions have either been removed or may be destroyed,
save harmless Pine View Crematorium from any and all claims and demands for loss or damages which may be made agate them
by reason of or connected with the cremation of said remains as directed,whether such claims or demands are or are not Jw(h�olly p
ground` false or u� ?v 00 S�r'I/oc'it G4 cQ U�/, �, �� U 7
(w (Address) U
(Signs of Relative or Legal Representative
Signed on this date: �� 3
Disposition of Cremated Remains
I hereby direct Pine View Crepoorium to dispose of the cremated remains as follows:
Mail to tj� IL
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
Revision:April 18,2007