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Carpenter, Georgianna
OF QUEE9,(,50UTO, PLNE VIEW CEMETERY AND CREMATORIUM WAXER ROAD, QUEF.NSBURY, NEW YORK 12804 (518) 745-4476 (518) 745.4477 Funeral Director Name e ! Case# Dace 0 f Crema t ion --17-0 Tame Cremation Started I, -3c Pals Tame Cremation Completed dk1 P Type of Container Remarks C�SeG(� iM 5 i J 0 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 Theuundersiggned requests and authorizes Pine View C torium,in accordance with and subject to its Rules and Regulations to cte the remains of SM '?b`AA � �k'10� l�©I�`7 (Street) (City) (S te) (zip Code) who died on of o R f/0 (Place) (Address) Name and address of nearpo kivi ngjWkathor name of a aertration: rAm o � 'C , FAR )Name) ( ) Relationship to the deceaspd `A Name of Funeral Home + + Nl� P: IMPORTANT: I represent that to the best of my knowledge,the deceased(has)ori0as r maker,defibrillator,battery,battery pack,power cell,radioactive implant or radioactive device in his or her body.(C ) I certify that I have full power and aufhortzation 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 harmiew Pine View Cremalpdum from any and all Bairns and demands for loss or damages which may be made against them r of ed with tion of said remains as directed,whether such claims ordemands areeoor ire nqt less,fai fra /J1l `wC' ' Awe ®Rr (Signaturd and Address of Relative or Legal Representative) Signed on this date: A'IRCA 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:April 18,2007