Purvis-Pitt, Elaine TOWN OF QUEENSBURY
Pine Virtu Cemetery nmd Cremintorium,
27 Qunker Rond, Qreensbury, NY. 72804-5902
(518) 745.4476 (518) 745.4477
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Funeral Director: Kk
Name of Deceased:
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Case Number: l
Date of Cremation: ti(- Z 5S -cj
Retort: ZP
Time Cremation Started: j', jo
Time Cremation Completed:
Type of Container: ,(1� w
Remarks:
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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 authorum Pine View Crematorium,In accordance with and subject to its Rules and Regulations to
cremate the remains of
��s 0V2",s -
(Name) (sex)
(Street) (City) (State) (Lip Code)
who died-on 2 day of ��
pace) (Address)
Name and address of nearest ' or name of
(Name) (Address)
Relationship to the deceased
Name of Funeral Hoare_� d 7L 6'Yb FLW cZ
IMPORTANT:
I represent that to the best of my Wewledge,the deceased(has)or no aker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her body.(Circle
I certify that I have full power and authorization to arrange for the cremation of the remains and to direct the c�postiion of the
crerted renrrwkrs,that any personal possessions have enitiner been rerrwved or may be destroyed.and agree to protect.defend arxi
save harmless Pina View Crenv*odum from any and al cieims and demands for foss or damages which may be made against them
by reason aonnecmd wilt erennedon of said mmains as directed.whedner suds ei mand
afrrns or des are or are not wholly
faise ��
(WI ) ( )
(Signature Address Relatiivve or Legal Representative)
Signed on this date: Z
Disposition of Cremated Remains
I hereby dlred Pine View Crematorium to dispose of the cremated remains as follows:
Mai to
other arrangements-Please specify:
If pulver=tion of cremated remains is requested,check here
Revision:Apri 18,2007