Bayer, Joan OF UEE B 2 L -`��(�s 211�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY NEW YORK 12804
(518) 745-4476 (518) 745-4477
_ Funeral Director 6C&C
Name OQh Ra'er
Case#.
Date 0( Cremation Oc{o�lr Z
�( 1601
Time Cremation Started
Time Cremation Completed
Type of Container C�of�, �/
�GSI�C ClAw ase, —
Remarks
A M
_ CooL
(j _l j
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 unders9ad requests and aut hortaes pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of
(Name) (sex)
(c�►i>n�n� ��� � ) cps)
(street)
(
� day of ��-rlhP� 2oS�
who died on
at Gins Fa11stLQlc_� 1t�Prr ti Sfi C�lonl NI� Ia 30
(Place) r (Address) '
Name and address of nearest rromg relative or name of person authorizing cremation:
a Wq
(Address)
Relationship to the demised 1 1 v s 60. —
Name of Funeral Home
IMPORTANT:I represent that to the best of my taWwledge,the deceased(has)or(has no)pecarnakw.defftl ator,battery,battery Pam.PDWer
cell,radioactive implant or radioactive device in his or her body.(Circle One)
I cartity that I have tj power and aug ortzabon to ananpe for the cremation of the remans and to drect the of the
have edhereen rem
been or may be destroyed,and agree to Pam•defend and
cremated remains,that any personal and an claims and demands for krss ar� h n�be made against them
save reason
f o pine View thennected witrh�cremadOn of acid Mmwns as directed,wttatlter such claims or demands are or are not wholly
by reason of e cr fraudulent
� b�
(signa a or Legat 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 spedfy:
If pulverization of cremated remains is requested,check here
Revision:April 18,2007