Jarvis, Vivian TOrNN OF QUEEN,5(13ur
PLNE VIEW CEMETERY AND CREMATORIUM
�y
QUAKER ROAD, QUEENSBURY, NEB, YORK 12804
(518) 745-4-476 (518) 745'-4.477
_ Funeral Director
��'ame �Ji�ti J hrV13
Case#
Date Of Cremation
- - I- 30 - 09
Time Cremation Started
7%Zo
Time Cremation Completed
fU • o
Type of Container Cho+L Css�
of 7, 20
Remarks
9 10 An
� : q0A
loot 10:00 An
i
i
i
I
i
i
i
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 authortzes Pine View Crematorium,in accordance with and subject to Its Rules and Regulations to
cremate the r mains of T _
(Name)
(fit) (city) ( (zip Code)
who died on 3 day of
F, P/ (at
l
(Place) (Address)
Name and ress of nearest living relative or name of person aW ift cremation:
(Name) ( ress)
Relationship to the deed 1'ux 6
Name of Funeral Home
1S
IMPORTANT: to the best of my Islwwledge,the deceased(has) (�no) §W,defibrillator,battery.battery per.pow
I represent that
cell,radioactive implant or radioactive device in his or her body.
1 ow*that i have full power and Mthorkation to aria W for the cremation of the remains and to direct the dWosition of f and
have ewer been ramovee!or may be destroyed,and agree Protect.
savetad remains.il��P from any 04 ag��demands for�or damages�t may be made against them
save with the cremation of said reed as directed.whadter such claims or demands are or are not who0y
by`mot or y
(Signature and of R Iative or egal Representative)
Signed on this date:
� 2 op
Disposition of Cremated Remains
i hereby direct Pine View Crematorium to dispose of the cremated remains as Mow '
Mail to
Other arnoVements-Please Spedfy:
if pulverization of cremated remains is requested,cdm&here
Revision:April 18,2007