McCoy, Timothy OF QUEErV593Ur
LNE VIES' CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY fix, YORK 12844
(518) 745-4476 (518) 745-4477
T Funeral Director vrI
Name �b
° C a s e # (02
Date Of Cremation
Tame Cremation Started
' ;me Cremation Completed � •, �- �
T r
Ype c : Container '�«! jI
t MVP(
�emar'�s
bar g :5'0
�L K� u
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 urndeiWied requests and authorizes Pine View Crematorium,in accordance with and subject to Its Rules and Regulations to,
cremate the remains of:
(Name) (sex)
35/ HAeRj69,,rzc. N y 1,03 7 i5
(Shim) (City) (State) (Zip Code)
who died on 71 F day Of Y r✓. 20j2j
at 35'/ //,4iZ@0,.xa fZD,5TWVY L'2FF.fz NY
(Place) (Address)
Name and address of nearest Wing relative or name of person authorizing cremation:
dINE fib' Ale�o� �S ��z��' Imo, �s�' Ny
(Nam) ( ) /2gy
Relationship to the deceased u ej/j
Name of Funeral Home
IMPORTANT:
I represent that to the hest of my Ivowledge,the deceased(has)00hi no maker.defibrillator or any other bettery operated
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 disposition of the
cremated remains,that any personal possessions have either been removed or may be destroyed,and agree to protect,defend and
sav Pine View Crematorium from any and all claims and demands for loss or damages which may be made against them
of or connected with the cremation of said remains as directed,whether such claims or demands are or are not wholhy
false`7
(W ) O
XLdd4
Signature and of Relative or Legal Representative)
Signed on this data. Z Y It)3
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
tMn )tw L✓/L� PAL(
Other arrangements-Please specify:
If pulver¢ation of cremated remains is requested,check here
Revision:January 1,2006