Scoville, Emileigh LO OF F QUEE9\�SDUT
WE DER' CEMETERY AND CRE
QUAKER ROAD, QUEENSSURY MATORTUM
(518) 745.4476 `'' YORK 12844
(518) 745-4477
DCl fah -SC(3Iiflle Funeral Director ...�
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in accordance with
and subject to its Rules and Regulations to cremate the remains of:.
D� mix-�--
(NamO (Sex)
13A- rnonI- tin st
(Street) (City) (State) (Zip Code)
who died on day of M AA&41 52 o 0
e .-, S /—u_//S S 0, f- - , / O O
(Place) (Address) -�J•
Name and address of nearest living relative or name of person authorizing cremations: (�
�P SS ►'C a— L / 3 .4 . /Y)D /i i czUm S f � �y �a.�s ���s� /
(Name) (Address)
Relationship to the deceased M 0 ')LA-0 --
Name of Funeral Home oax-ie-enuner l Heue Inn
IMPORTANT: A
I represent that to the best of my knowledge, the deceased has or hano
pacemaker in his or her body. (Circle One)
I certify that I have the 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 not wholly groundless, false or fraudulent.
'Do, -q.q Ar�t4l3i
(Witness) (Address) Al,
(Signatur ofRsqativ gal Rep. and Address.)
Signed on this date: 3
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in accordance with
and subject to its Rules and Regulations to cremate the remains of:
E rn + let nnt��o► ov;il e rPrn ��
(Nam6) (Sex)
(Street) (City) (State) (Zip Code)
who died on day of _hD&A_,, . Zoo o
atV/G �-)S f-a_ Iis 5 /�, r� l /OD ;f�r� ) I, to " S �cLs , Al-A-
(Place) ( ddress) i AS11/
Name and address of nearest living relative or name of person authorizing cremations:
Leai=1 i 13,4 MwC calm Sty �v /�n S
(Name) (Address)
Relationship to the deceased M '* 36 P✓
Name of Funeral Home Gar —al He T
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or has no
pacemaker in his or her body. (Circle One)
I certify that I have the 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 not wholly groundless, false or fraudulent.
�yr►�.� � � � /YI d -� S r, �u �t �,- �-f js, IU t/
(Witness) (Address)
(Signat rem elativ Legal Rep. and Address.)
Signed on this date: