Fischer, Judith �O OF QUEE9�(,50Ur)�TpWE
VIEW CEMETERY AND C
QUAKE QUBENSB
R ROAD, REMATORIUM
URY, trEW YORK 128N
(518) 745-4476 (518) 745•-4-477
_ Funeral Director ��
Name � ��L _ lhg KILtIF4
�kL�r Case#. 3Z
Date Of Cremation
Tame Cremation Started
3a
Tame Cremation Completed
Type of Container
'—
Remarks (Sr
�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
The undersigned requests and authorizes Pine View Crematorium,in accordance with and subject to its Rules and Regulatbns to
cremate the remains of.
( rne) (Sex) _
Lb
( reet) (City) (StateV N Code)
who died on 1 6 e day of aa ll 20op c—
_ /
at bo r� 1 d-&,!o
(Place) 1 (Address)
Name and address of near living relative or name of person authorizing cremation:
(Name) 0 (Addy
essl
Relationship to the deceased / v
Name of Funeral Home M R Ki 1 mPr PLnPra 1 Home
IMPORTANT:
I represent that to the hest of my knowiedge,the deceased(has)or(has no)pacemaker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her body.(Circle One)
I certify that I have full power and authorization to anenge 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 or are not w ity
groundless,false or fraudulent.
�J (Witness'
(Address)
' 1 (Signature and Address of Relativnxe/or legal Representative)
S+gned on this date: / �/6 '✓
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
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 undersigned requests and authortres Pine View Crematorium,In accordance with and subject to Its Rules and Regulations to
uemate the remains of:
1�a AA
( me) (Sex)
( eet) (City) (Star ( Code)
who died on 6 day of 20k c—
at Coo o-t4A.P Fa- -AL-Y9 t
(Place) (Address)
Name and address of near living relative or name of person authorizing cremation:
(Name) (Add r
esslf
Retationsnip to the deceased
Nameof Funeral Home M R Xi 1 mer Pitnera1 Home
IMPORTANT:
I represent that to the hest of my knowledge,the deceased(has)or(has no)pacemaker,defibrillator,battery,battery pacts,power
cell,radioactive implant or radioactive device in his or her body,(Circle One)
I certify that I have full power and aumortzation to arrange for the cremation of the remains and to direct the disposttlon 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 or are not wholly
groundless,false or fraudulent.
(Waress) (Address)
(Signature and ass of elative or Legal Representative)
S+gned on this date:
Disposition of Cremated Remains
hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mal to
Other arrangements-Please specify:
if wivertzation of cremated remains is requested,check here
Revision:April 18,2007