McMahon, Mable y�
OF QUEE9\�5OUr
PINE VIEW CEMETERY AND CREMATORIUM
QU^KER ROAD, QUEENSBURY NEW YORK 12804
(518) 745-4476 (518) 745.-4477
Funeral Director M
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Date Of Cremation Z Z ? a �/
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Cremation Started - tiU PO A
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Tame Cremation Completed
Type of Container
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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 auftrizes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
�'labte G. H ' M &hOn re�A0,
(Name) (-Sex)
) LaCo,---)cl -Dry-f- -anseucn�+ N '�
(Street) (City) (State) (zip Code)
who died on _ -7 day of CC h ru a.V- 20_nS
at I LEa I-D 1 )Y�J� Ct n sf'y�7 `� 8 3
(Ph") (Address)
Name and address of nearest living relative or name of person authorizing cremation:
1 1` ►� ) La vr- I r� e, Ga-�nS�L?00A � qj y
(Name) (Address)
Relationship to the deceased
Name of Funeral Home to e
IMPORTANT:
I represent that to the best of my Ivawledge,the deceased(has)Cr has no) er,defibrillator,battery,battery pack,power
cell,radioactive implant or radloaWve device in his or her body.(C
I certify that I have full power and author a tion 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 with the cremation of said remains as directed,whether such claims or demands are or are not wholly
groundless,false or fraudulent.
(Witness)If (Address)
3W �
(Signature and Address of Relative 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 pulvetzbon of cremated remains is requested,check here
Revision:April 18,2007