Butchino, Grace OF .QIUEEN,5BUT.
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY NEW PORK 12804
(518) 745-4476 (518) 745-4477
\ame
Funeral Director B�EWE
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Date Of Cremation
Time Cremation Started
4:is
Time Cremation Completed o :20
AM
Type of Container ��Ir odfrp Crq.r
Is i C,qX-
Remarks
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(oat :2b�
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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 audtoriaes Pine View Crematorium.in aocordanoe with and subject to its Rules and Regulations to
ate the remains of:
(Sex)-- (Sweet) (CAY) C1t C P i (Stag (�P )
who died on 1 day ofJCLY) 20—IL09
at It ilS 5p-10 —
leoe) I O
Name and address of nearest living retain or name of person a tiort t'g aerrtOW:
Address)
ReWonahip to the deceased r--c �a i••� ---
Name of Funeral Home T�qi,c?f'
IMPORTANT:
I represent that to the best of my Knowledge,the deceased(has)or(has no)peoerrra W.dOGYNOW or any Ww battery operated
device in his or her body. (Carle One)
I certify that I have full power and a gwization to arrarpe for the aamadon of the remains and to direct the disposition of the
aemeWd remains,that arty personal possessions have either been removed or may be desVoyed.and agree to protect defend and
save hanrdess Pine View Creastartttm from any and ON daunts and demands for loss or damages which may be made apaittst them
by of or corrtected wilt►the cremation of said remains as directed,whether such delrrrs or demands we or are not wholly
isles or iraudcrler►t.
(yy ) (Address)
— (Signature an-d�Address of Relative or Legal Represertative)
Signed on this date: -_1 1-7
Disposition of Cremated Remains
I trercrUy direct pine View Crematonum to dispose of the cremated remem as Mows
Mad t0
Odrer arrangements-Please specify: D? ^
if pi*Mj ation of c rarnated remains is requested,dredc here 2--
Revision:January 1,2006