Motian, Mary OF QUEE9\�5DUQ�y
PINE VIEW CEMETERY AND CREMATORIUM
WAXER ROAD, QUEENSgURy NEW YORK 12804
(518) 745-4476 (518) 745.-4477
Funeral Director r�
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Date Of Cremation
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Time Cremation Started
Time Cremation Completed I1•-Lu 1111
Type of Container
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 accordance with and subject to its Rules and Regulations to
cremate the remains oF.
Nogg c� F
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(Street) (City) of (State) (Zip Code)
�bY2vnh 20 0�
who died on G'2' ,i{f A ld� �� � . ���
ac�(�S� �r tux
(Piece) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
John OOHOA 10 �Jocg)stOe Ate. �6� ta�o3►
(Name) (Address)
Relationship to the deceased
�,�
Name of Funeral Homer
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(hes no)pacemaker,defibrillator,battery,battery pack,power
cell,radioactive Implant or radioactive 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&acted,whether such claims or demands are or are not wholly
groundless,false or fraudulent.
(Witness) _. (Address)
(Signature and Address of Relative or legal Representative)-
Signed on this date: 1 GD ?—I, Zoo
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
other arrangements-Please specify:-'R10rZQ k.X3 /
If pulverization of cremated remains is requested,check here Y
Revision:April 18,2007