Cameron, Sarah ft
OF QUEEN,5BU-r�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QLIEENSBURY, NEW YORK 12804
(518) 745.4-476 (518) 745-4.477
Funeral Director_ �E�
.Name a ��
o�oti Ca s e# _ L�
Date Of Cremation �-- Z3 -- 0$
Time Cremation Started 12 :25- �h
Time Cremation Completed Z ;SS
Type of Container etd�� C�S�f 2019 CASE C
Remarks
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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 N*Wrtms Pine View Crematorium,in accordance with and subject to Its Rules and Regulations to
cremate IN remains of:
i-
1�' (sex) �2(�
(Name)
(Street) (City) (State) ' (ZP )
who died day f 20 CU
�r
(place) ( )
Name nd address of nearest raving relative or name of cremation:
F v
(Name)
Relationship to the deceased
Name of Funeral Home
IMPORTANT:
I represent that to the best of my browledge,the
hde deisor her ceased (or no) •defibrillator,battery,be"Pack,porn
cell,radioactive implant or radioactivedevice in
I certify that I have full power and aadtrorization to amnia for the cremation of the remains and to direct the disposition of the
cremated remains.that any Personal possessions have either been removed or may be des yed.and agree to Protect,defend and
save harms Pine View Crematorium from any and an daims and demands for loss or damages which may be made against them
by reason of or connected with the cremation of said remains as darec.'ted,whWw such debris or demands are or are not whopy
groundless,false or fraudulent.
.tea„ —
(w ) (Address)
(Signature and of R or legal Representative)
Signed on this date:
` �
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:
If pulverization of cremated remains is requested,che&here
Revision:April 18,2007