Haigler, Grover TOrMN OF
QUEEN,5BU-r�y
PINE VIER' CEMETERY
AND CREMATORIUM
QUAKER ROAD
QUEENSBURY, NEW YORK 128N
(518) 745.4476 (518) 745.-4477
Name
Funeral Director
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Case# Z�
Dace Of Cremation
— -
Time Cremation Started I:vs
Time Cremation Completed 4110
Type of Container
Remarks S
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, New Y", 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 subject to its Rules and Regulations to
cremate the remains of:
ro ver C . a; Le/ R(A
(Name) (Sex)
(Street) +� ram- (City) �^ (State) (Zip Code)
who died on l day of -1 20 at�
(Place) ress)
Name and address of nearest living relative or name of person authorizing cremation:
k&,� T l rCtrSle/ -7-f' c (a ref JGY -
(Name) (Address)
Relationship to the deceased b�ca i
Name of Funeral Home
IMPORTANT:
I represent that to the best of my lo�e,the deceased(has)or(has no)pacemaker,detibriltator or any other battery operated
device in his or her body. (Clircie One)
I certify that I have full power and authorization 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 Pine View Crematorium from any and all claims and demands for loss or damages which may be made against them
by reason of or connected wkh the cremation of said remains as directed,whether such claims or demands are or are not whdty
ro }eas, lent. _
(witness (Address)
(Signature an44,ddress of Relative or Legal Representative) T
Signed on this date: �JC—A
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,check here
Revision:January 1,2006