Costanzo, Frank OF QUEE9�50U ,
PLNE InEW CEMETERY AND CREMATORIUM
QUAKF-R ROAD, QtjBFNSgtjR.r NEW YORK 128C4
(518) 745-4476 (518) 745-4477
Funeral Director DCtiSh�R�
F a m e "Ile C05+50%L6
Casey 190
Dace Cremati.on
T :me Cremation Started �: US --
T : me Cremation Completed —
Ty
pe " ' Container 1 L _
UAi� bi 61 r
RemartCs
5 '3060
IU:2o�
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
cremes the remains of:
(Name) (sex)
(Street) (City) (State) (Zip Code)
who died on / `/, �� day of ��j�f—LA e�r2 20�
j
at / 1 0� `7-e. - Z Z
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
Re ve-r j -,e-
(Name) (Address)
Relationship to the deceased �� �'C-c—
Name of Funeral Home H, I,
IMPORTANT: �'�
-1 z I represent that to the best of my k ri ledge,the decet (has rho) er,defibriitator or any other battery operated
device in his or her body. (Girds One) .,`_�
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 whdfy
groundless fraudulent.
er,. 4e r,,&L.
Hess Address --7•-•_ —__.___.._.____�.�_.._.
(Signature Address of Relative or Legal Representative)
Signed on this date: G t d a7
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 pulverization of cremated remains is requested,check here
Revision:January 1,2006