Chrostowski, Stanley �O O�7�I �Q F QUE
PINE VIEW `� " � ���
CEMETERY AND CREMATORIUM
QUAK-ER ROAD, Q( EENSBURY NEW YORK 12844
(518) 745-4476 (518) 745.-4477
Funeral Director
Fame �—
C rostawSel - Ca s e#
Date Of Cremation
Time Cremation Started
Tame Cremation Completed
_ Iv
Type of Container
Remarks
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("Dek, 10- 3o AM
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 wthortzes Pine View Crematorium,In accordance with and subject to Its Rules and Regulations to
cremate remains of: ,cam
(Name)
Sex
33 -- A�, d�839
(Street))9 (City) (State) (Zip Code)
who died on eft day of ��� 20k�
at T e 7 , n 4
(Place) ( )
Name and addMn of nearest Wing reladve or name of person au"Wrb tp aemadont:
cmw-
(Nam) � (Address)
Relationship to the deceased�5 -/
Name of Funeral Home a u& Q'VIL`Z-
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,defibr ,Wor,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 authorization to arrange for the cremation of the remains and to direct the dispostdon of the
cremated remains,that any personal possessions have enter been removed or may be destroyed.and agree to protect,defend and
save harms ess Pine View Crematorkm from any and aii cte' n and demands for krss or damages wtrich may be made against them
by reason of or connected w1h the awrie rt of said remains as dratted.whether such carols or rip mards are or are not wholly
false or fraudtdertt.
x C2 c�
( )
(SignatureQQard of Relative or Legal Representative)
Signed on ails date:1i
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mae to
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
Revision:April 18,2007