Scoville, George OF l,l�L
Q 9\�SB U1R_y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12844
(518) 745.4476 (518) 745'-4477
Funeral Director Rl $ I'YInQ
Name 6'-e-Or5e_e 1I IC
C a s e#
Date Of Cremation
Time Cremation Started C) P} f I
Time Cremation Completed � l/0 p
Type of Container RA C5
Remarksr�
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12804
i 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
cremate the remains of:
6e-or SCa V le--
(Name) / (sex)
i l
�I Lph LAY l�.zc,^c � Y
(Street) 1
(City) �/► (State) (ZIP Code)
who died on I day of 20 d
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
Leo^,k M . xL I,c -� I 1 A "/K lei t ZA z
(Name) �nyn� (Address)
Relationship to the deceased
Name of Funeral Homee^5M
IMPORTANT:
I represent that to the best of my Iviow{edge,the deceased(has)or has no)pacemaker, lator or any other battery 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
save harmless Pine View Crematorium tram any and all claims and demands for loss or damages which may be
Y made agairtst them
by reason of or connected with the cremation of said remains as directed,whether such claims or demands are or are not whdiy
gro less �fraudulent. //� !�l
y AC Jr., Fv
(witness) n (Address '
V�
(Sign ture and Address of Relative or Legal Representative)
Signed on this date: wf v�� 5 ,� ob tY
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