Cleveland, Francis OF QUEEN�BUr�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QtlEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 0tn5CAOr-t
Name F—tc„'C(5 CI��C�c�r�
Case#,
Date Of Cremation
Time Cremation Started
T 30 �M
Time Cremation Completed q-, q0
Type of Container A� or�(� -F4, IST CA)
Remarks
T-
icrock �U n
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:
CLeve Lk-,
(Name) ( )
ze
(Street) (City) (State) (Zip Code)
who died on ! y dray of �.0�`v !t 2o_7
at Ste.r y �vc �, SKr-
(Pla,ce) (Address)
Na and address of nearest 4 living relative
relative or name of person authorizing cremation:
a rA � S-" k /s 6. i �•2��.
(Name) I (Address)
Relationship to the deceased
Name of Funeral Home e r
IMPORTANT:
I represent that to the best of my ivtowiedge,the deceased(has)or no)pacemaker,defitxiltator or any other battery operated
device In his or her body. (Cfrde One)
I
I certify that I have full power and authortzation 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 otg connected with the cremation of said remains as directed,whether such daims or demai9cls are or are not whdly
y' ground fraudulent. .
r II
t (Wit (Address) r
(Signature and Addr f Relative or Legal Representative)
Signed on this date: /� S y, 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: jl
If pulverization of cremated remains is requested,check here
i
Revision:January 1,2006
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