Simpson, Ralph OF
QUEE�93ur
PINE VIEW CEMETERY AND CREMATORIUM
WAXER ROAD, QUEENSBLMY NEW PORK 12844
(518) 745-4476 (518) 745•-4.477
Funeral Director $ l
�.
e/'
Fame .. I Mf 301.
Case# 10HC
Dace 01 Cremation
Time Cremation Started
Ta me � 3v
Cremation Completed g T
0
Type of Container MIGU
Remar'xs
N kd
• UO
Feb 27 08 09:27a 5revver Millar Di0-OyC-Ll1FJ N�
163
Town of Queensbury
Pine view Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Offlow.(518)745-4476,Crematorium: (518)745-4477
Authorization to Cremate
The undersigned requests and auttrortzes Pine view Crematorium,in accordance with and subject to its Rulas and Regulations to
cremate thts remains of:
(Street) (Cgy) (Sidi } (zip code)
who died on _ �1.� day of �P /vCi`` 20-62
at ( (Address}
Name and address of nearest riving relative or name a1 ,person atrlrwrixirV cram
,!/
/ �' /✓C� j<r�J� 2 hl / f? -117
(Name)
Relations*to the deceased
iMPORTANT: �I
i reyxesant that to"test of my knowledge,the deceased(has) (has no cemaker,deMrifietor,battery,battery Peck, r
ctt
oeil.iadioave implant or radioactive device inhis or her body.( ei
I certl y that l have fug power and autte txatiOn to arrange for the cremation of the remits and to direct the So p�roOn Of de and
c5ernated remains,thet any pef+,so vi Pa'�sbna have ekher been removed or may be destroyed,
aro save harmless Pine view Crematorium from any and all claims and demands for ions or damages which may be made against them
by reasonQf or Oogjpg6ed wkh the cremation of said MMSWIs as directed,whether stxh dairns or demands are or are not wooly
frauc
(Witness) (Address) __--
(Signature)and Address of RQ ive or Legal Representative)
Signed on this date: .--�;- O
Disposition of Cremated Remains
hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to ----------
Other arrangements-Pk-a spedfy'.
;i putver fcatior#cif cremated remains is requested,check!'sere— —
RevWon:April 18,2007