Orne, Samuel N '
TO rNN OFQUEE9�5BU-r�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
1 Funeral Director h(� kT�F1EQ
Name Sal uei 0 ►�
Case# 3?
Dace Of Cremation
Time Cremation Started
I��D
Time Cremation Comple ed
Type of Container v� p
Remarks
N ; zo �h
D 2:od
Z .3a
3.oaP
., GQaL
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 authorizes Pine View Crematorium,in accordance with and sub)ect to its Rules and Regulations to
cremate the remains of.
(`-(Name) (Sex) t 1
(Street) (City) o (State) (Zip Code)"
who died on day of 2015�
at "L-
(Piece) (Address)
Na7and address of nearest living relative or name of person authorizing cremation:
e bP Cr « U rn e ) �� �(L' s n,k a F L-ao
(Name) (Address)
Retationship to the deceased '� �� �jp r
Name of Funeral Home M R Ki 1 mer Funeral Home
IMPORTANT:
represent that to the best of my knowiedge,the deceased(has)or(has no)pacemaker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her body.(Circle One)
I certify that I have full power and authortzation to arrange 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 destroyed,and agree to protect,defend and
save harmless P' Cr um from any and all claims and demands for loss or damages which may be made against them
by reason of or ed cremation of said remains as directed,whether such claims or demands are or are not whdfy
groundless,
virtnesq) _ (Address)
(Signature and Apess of lative or Legal Representative)
Signed on this date: -7 C
Disposition of Cremated Remains
I hereby direct Pine View Crematortum to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
Revision:April 18,2007