Carchietta, Michael 2O� � OF QUEE (3
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PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY NEW YORK 12844
(518) 745-4476 (518) 745-4477
Funeral Director
Name �C�tid
art Lt ,�,
Dace Of Cremation Z _
Time Cremation Started
Time Cremation Completed (0 ; 10
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 authorizes Pine View Crematorium,In accordance with and subject to its Rules and Regulations to
crenrote the of k —
(Name) ( )_7D A1gir-� 6e t
(meet) (City) (State) (zip Code)
who died on � n day of ,� 20_J�
at
(Place) (Add ess)r
Name and address of deafest living fivJe or name of person authorizing cremation:
�-
(Name) (Address)
Relationship to the deceased
Name of Funeral Home �kCt
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has Cor(has no) maker,defitxillator,battery,battery pack,powercell,radioactive implant or radioactive device In his or her body.
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 with the cremation of said remains as directed,whether such claims or demands are or are not wholly
groundless,false or fraudulent.
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(witness) (Address)— —
(Signature and Address of Relative or Legal Representative) j
Signed on this date: 2—Z 0�-
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Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
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Other arrangergents-Please specify:
If pulverization of cremated remains is requested,check here
Revision:April 18,2007
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