Higgins, lloyd Jr. OF QUEEN
5 B U TT
PWE Y1E'PY CEMETERY AND CREMATORIUM
QUAKER ROAD, Q SgURY NEW YORK 12804
(518) 745-4476 (518) 745--4-477
Funeral Director Sfig� �fc�
Name `
a'ydJj Case#. �15
Date 0( Cremation Ucfd�c' Z
Time Cremation Started
12,30
Time Cremation Completed pM
Type of Container C'
u r ace 2 A;f7 C/{5 E
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
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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:
LLgCA,Q Oou aL VS- 4\ ,- I (QS �P- MALE
(N ) (Sex)
o g4,<-
(Skeet) ( ity) (Star ) p Code)
who died on day of CC:%BF-,(2 , 20_Q�
at S
(Place) (Address)
Name and address of nearest living relative or name of person authoriz(ng cremation:
LARo L 71. 4Gi . —�7 Hk&&tto� Ro L,�Kf; C�op-c�,-n�
(Name) (Address)
Relationship to the deceased m i f E
Name of Funeral Home
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or has no) maker,defibrillator or any other battery operated
device in his or her body. (Circle One)
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 wholly
groundless,false or tfraudulent.
2;
�— (W (Address)
kE � � ��ag
(Signatu f Relative or Eegal Representative)
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 pulverization of cremated remains is requested,check here_
Revision:July 7,2004