Duffy, Douglas TOrklN OF QUEE9�5BU-r�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name v (q5
Case# 5'
Date Of Cremation i�
V¢6cAnbl r 13 Z 0
Time Cremation Started
Time Cremation Completed :Z O
Type of Container Ar tnr rG -�u,�Q
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Remarks
7: 35-
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531
Town of Queensbury
Pine Yew Cemetery and Crematorium
21 Quaker Road,Queensbury, Now York, 12804
Cemetery Office:(518)745-4476,Crematorium: (518)745-4477
Authorization to Crenate
The undersigned requests and aut orims Pine View Crematorium,in accordance with and subW to its Rules and Regulations to
cremate t7emains of:
(sex) /
Z to )/V 0 2%�t�k J �,J C S �tJ ,� � !!o (J/LTU�J � 2c�3
(Street) _ (City) (SUAS) (Zip Code)
who died on '"'t`'ti day of 20!
at
(Piece) ( )
Name and address of nearest living relative or name of person authorizing
(Name) ( )
Relationship to the deceased LJ/ I-&r
Name of Funeral Home
IMPORTANT: detibetor. y battery Pack.Psi
i represent that to the best of my lahowledge,the deceased(has)or(has no)paoenhaker.
cell,radioactive implant or radioactive device in his or her body.(Circle One)
I certify that i have full power and auawrization to arrange for the Mmalion of the remairhs and to direct the disposition of the
cremated remains,that any personal possessions have ellim been removed or may be destroyed.and agree to protect,defend and
save harmless Pine View CfenvAorlum from any and al claims and demands for b w or damages which may be made against them
by reason of or connected with an cremation of said reertins es drrecied.v*m* r such claims or demands are or am not wholly
groundless,false fraudulent. /' O
(Witness) J)r, (Address)
Z � '7
(Signature of R or Legal Representative)
Signed on this date: Z �z
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as foUaws:
Mail to
Other arrangements-Please speclfy:
If pulverization of cremated remains is requested,check here
Revision:April 18,2007