Burch, Virginia TorNIN OF QUEEN,5BUr�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, O EENSgURY, NEW YORK 128o4
(518) 745-4476 (518) 745-4477
Funeral Director
Name 1f(f° ` pu�C�
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Date Of Cremation No..,04A
Time Cremation Started
i2 -yo Ptij
Time Cremation Completed Z" )trl
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
crematethe remains of:
d I
(Na (sex)
(Street) / J (City) (State) 0—ode)
who died on ` L ��S1— 0 day of 20
at
(Place) (Address)
� Name and address of nearest living or name of person ak><tiormng cremation:
:r%�.�ft�'
(Name) (Address) CJV
Relationship to the deceased
Name of Funeral Home ^Y�=
IMPORTANT:
I represent that to the hest of my knowledge,the deceased(has)or(has 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 File View Crematorium from any and all claims and demands for boss 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 fraudulent.
.(Witness) ', (Address)
(Signatur nd Address of Relative or Legal Representative)
Signed on this date: ` ,-/6r 7
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