White, Clinton OF QUEENB T
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSgURy, NEW YORK 12804
(518) 745-4476 (518) 745-4477
I Funeral Director CVE
Name
Case# 55�
Date Of Cremation
eepM�r Z� 2 06 1
Time Cremation Started 7; 3u
Time Cremation Completed 30
Type of Container F(' (,{.
r lEE 1 Srt'
Remarks
Y Y0
1;10 #
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Town of Queensbury
Pine view Cemetery and CremattariUm
21 Quaker Road,QueensWry,New York, 12804
Cemetery Office:(518)745-4476,Crematorium: (518)745-4477
Au#Kw z#W bD Cremate
The undersigiried requests and aufhorees Pkw View 06mmorkim.in accaorder>ce with and wbject to Its Rules and Regulations to
cremate Bte remahis of.
rilh7UY1
(Name)
street) (om) Ipt te) (Zlp code)
who died on day of�l 6- 20 Q`2
at 1 -
(P ) }
Name and address of nearest aving retaave Or name of PWM su#mrb*V aemaeon:
(Name) (Address)
RelmionsW to the deceased nx-c C—-
Name of Funeral Fkxrte
IMPORTANT: the deceased(has)0101T ndl pacemaker,defir r or any other bAft opera
t represent that to the best of mY knowledge. ....J
device in his or her body- (Ckde One)
I certify tttat I have fu8 power and a AWftm on to arrange for the c reeraaon of the remains and to dwac t the disposition of the
cremated remains,that any persorid possesebm hem altim been rec oved or may be destroyed.and agree to protect,defend and
save hwmiess Pine VIAW Glrema orkn floor any and all dW W and deow ds for Ines or dattteges which may be now aPW them
by reason of Or conrtec.'ted the aldnetion of said remains as directed,whether such or demands are or are riot wholly
tom•false or '
1 1�~ r
(Address)
Ai
(signatcae ArufAllelress Of Hewn Or 1�90 RePreserAetive)
signed on this date:
Disposition of Cremated Remains
I hereby daect Pine View Crematorium to dispose of the cremated remake as follow&
Mam to c r�
other arrangements-Pleeae sp,dfy: hP a r/' A n
If p N&uation of cremated remams is mWested,dw&here X
Revision:January 1,2006