Landsiedel, William OF
PINE 9QUEE \�593Ur
_
�E�' CEMETERY AND CREMATORIUM
ROAD,
Q FNSBURY, NEW YORK 1280,4
(518) 745-4476 (518) 745-4-477
�1I�I Funeral Director z
4 C a s e# 7$
Date OF Cremation � 0�
T )
Cremation Started
T ;me Cremation Completed
Type Container �p _
Remar'F, s 5 f
2,
3:10 F17
Town of Queensbury
Pine Yew 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 authortzes Pine View Crematorium,in accordance with and subject to is Rules and Regulations to
cremate the remains of:
W'►I1tam A. LQnc skedet HQA 9
(Name) (Sex)
32 Grwtz fyv e. G lens FLAV, �JeA-0'�Of- 1280
(Street) (City) (State) (Zip Code)
who died on E=-bruan., day of, 3 20QB
at G6S Vaal flux t -I -; Cjk-ns �I IS ' NC'vj yC)r 1L 12801
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
Mr r+hc,.I-anSiec-e 1 32 Grove- Ave G Q_ns FaLl Is Kht ►2bo I
(Name) ( )
Relationship to the deceased W 1.l S�—
Name of Funeral Home_TIlC7J� �Yl �(12t( `L'iC�(lfl.�
IMPORTANT:
i represent that to the best of my Wwwiedge,the deceased(has)or(has no)pacemaker.delibrliator,battery.battery peak,power
cell,radioactive implant or radioactive device in his or her body.(Circle One)
I cat*that i have full power and WANXi0011 to anarW for the awn tlon 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 Caremutoriun from any and al daims and demands for loss or dateneges which may be made against them
by resort of or connected vAh the aemabon of said remains as directed.wester suds dafm or demands are or are;not wholly
groundless,false or
dress) ( )
(Signature and Adldress or Legat Representative)
Signed on this date: Z 1 I
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,deck here
Revision:April 18,2007