Mastrianni,Joseph i_
TOrNN OF QU EEN,5BUTr
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUERNSgURY NEW YORK 12804
(518) 745-4476 (518) 745-4477
_Name Funeral Director_ (_C-�� DCNNj
J ySePL
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Dace Of Cremation ti►o .�rnl�c�
Time Cremation Started -.-
Time Cremation Completed lb(./6
1
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.
Joseph W1asf iayau- Wt
(Name) (Sex)
(Street) / (City) (State) (Zip Code)
who died on ll/� day of ���• 20DJ
at JuKi wir I d1'la. tnAx LAmblisl b- Y-�Y'
(place)I (Address)
Name and address of nearest living relative or name of person m creation:
1�1 riawt kta-S �Ua�i� 1' o I Ld d I Y 4
(Name) _ (Address)
Relationship to the deceased �y I c(✓
Name of Funeral Home
IMPORTANT:
I represent that to the best of my Ivowledge,the deceased(has).#(has WAMcernaker.defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device In his or her body.(CVEW 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 eason of or connected with the cremation of said remains as directed,whether such claims or demands are or are not wholly
rxlless,false or lent.
' ,.0
(w' ( )
(Signature and Address of Relative or Legal Representative)-
Signed on this date:�I I I
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify. �ZG TLf PZ ICJ i� ✓ �l!U[= �' f'�CY�G
If pulvertzation of cremated remains is requested,check here
Revision:April 18,2007