Kaciak, William OF QUEE9�5BU-r�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURy, NEW YORK 128C4
(518) 745-4476 (518) 745.-4477
Funeral Director R�G�i� PEPNj
Name II An, KaCltik
Case#
Date Of Cremation
Time Cremation Started
Time Cremation Completed
Type of Container
Remarks
YN
MOVE g SAY
9 U Ail
(00L.
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 ct 'y 1
[ k);) l1r�m J aC1m /� Y; c17
(Name)\ —7 ()Sex)
L\ / d / oa'7
(Street)i (City) (State) (Zip Code))
who died on \— ✓'liar s da•, \ \day of / 2007
at C� lcnsa)) s H aa.�_
(Place) (Add )
Name
�and
�address of nearestliliving relative or name of person authorizing cremation:
1 ✓a; )6 JS av)a�
(Name) (Address)
Relationship to the deceased
Name of Funeral Home '(�c N )j ,
IMPORTANT:
I represent that to the best of my iviowledge,the deceased(has)or pacemaker,defibrillator.battery,battery pads,power
cell,radioactive implant or radioactive device in his or her body.(Cirdi�t)
I certify that I have fuU power and authorization to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,that any personal possessions ve either been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View Crematorium from any all claims and demands for loss or damages which may be made against them
by reason of or connected with the cremati" remains as directed,whether such claims or demands are or are not wholly
groundless.false �t. �:
dress) (Address)
(Signature and Address of Relative or Legal Representative)-
Signed on this date: Z 7
x n
U /
Disposition emains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to R c -�-,-S, -o 1�
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
Revision:April 18,2007