Nesbit, Helen TM+N OF QUEEN,5BU-r�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSgURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director Ro�grk A.L -
Name f[ � lS `
Case#
Date Of Cremation
- � D
Time Cremation Started to
Time Cremation Completed 3: /U �M
Type of Container
Remarks
M N Mvv
.. Z• 30 �
llec 24 07 08: 25a Robert Nesbit 706 733-8861 p. 2
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury,Now York,12804
Cemetery office:(518)745-4476,Crematorium: (518)7464477
Authorization to Cremate
The undersigned requests and authorizes Pine View Crematorium,in accordance with and subject to Its Rules and Rogtd ftw to
cremate"roma4lg at
/.',
(Nam
(street) V (CRY) " ~J (/State) (ZIP Code)
who died on day M 20AI
at 40%o4z'-J-
(Place) (Address)
Name and address of nearest living roislive or norm of person ovlhortzfno cremallon:
(Name) (Agtxess)
RotaUonshtp to the deceased. a
Norma of Funeral Home ga e- l MW Cz
IMPORTANT: pacemaker.debbrieator or arty Oe1ar ballwy operated
t represent that(0 tfw hest of my taiowted0e.the deceased(hors)
dovlee in his or her body. (Cirds Ono) s no
i Codify that I have full power and authortmUon to orange for the aematloo of the remains and to dfred the dlspoelUon of the
emmaled remalna,that any pefsoml poneWons have either bean removed or may be destroyed,end Wee to pr UC%defend and _
gave hwmfew pine View Crematorium from any end at claims and demands for loss or damages vdtich may be trade apokuA than
by mown of or eortnecled with the crenwtion of sold remains as directed,whether such claims or demands erg or are no wholly
groundless.false or hau&denL
X as a La
'X (s re gtrgd Address or titre or Legal Represenw0m)
Stoned on this date:
Disposition of Cremated Remains
I hereby rprect pine Viaw CramaWrtum to dispose of the cremated remalns as follows:
Mail ter n
OUterarrenpemenls-Please spedly Mold ti.-•� S
If pulvwbmUon of cremated remains Is requested,check here
Revbkx:January 1.2006