Gillmitt, Jane OFQUEE9�5BUr��
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSgURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Director
Fame Funeral
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Case#. L
Date Of Cremation vEtohtr
2oo7
Time Cremation Started
Time Cremation Completed
1
Type of Container a,
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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 authorizes Pine view Crematorium,in acoordance with and subject to its Rules and Regulations to
cremate the remains of:
(Name) ( )
(Street) +� ) i rd (City) �) (state)1) s (Zip Code)
who died on 17 day of c 20 67
at C�Z�r s �4)1 z �Z . -
(place) ('6MMM
Name and address of nearest living relative or name of person authorizing cremation:
-/J4v r cl ll"f U o r Z11,J,
(Name) (Address)
Relationship to the deceased
Name of Funeral Homey
IMPORTANT: maker,defibrillator,battery,battery pack,power
I represent that to the best of my knowledge,the deceased(has)(C (has a
cell,radioactive 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 any and all dalms 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,whather such claims or demands are or are not whotly
groundless,false or fraudulent.
(VV. ) (Address)
(Signature and of Relative or Legal Representative)-
Signed is date: j0 )j06-:)
X4s�� /-49/1
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:April 18,2007