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Stamper, Walter TOWN OF QuEENSBLIRY Pine View Cemetery and Crematorium 27 Quaker Road, Queenshttry, NY. 72804.5902 (518) 745.4476 h<<P t/',"v`v.queensbury.net (518) 745.4477 Funeral Director: f Name of Deceased: �� p+ S +e f Case Number: Date of Cremation: I- Z Retort: :"r CAS Time Cremation Started: v© Time Cremation Completed: II ; 4 U Type of Container: a� �oarc Remarks: 5c' " Home of NaIitraI Benitty ... A 000it Ptnce to Liue " Town of Queensbury Pine View Cemetery and Crematorium 21 Quaker Road,Queensbury, New York, 12MM Cemetery Office:(518)7454476,Crematorium: (518)745-4477 ' Authorization to Cremate The undersigned requests and author ss Pine View Crematorium,In accordance with and subject to its Rules and Regulations to cremate the remains oh: UY a I ra il 5-OH !' /a�P�Y rI-� / l►�r,� (Name) (Sex) who died on 1 day of 20jLl� at /N•S 1�gc (place) �'O Name and address/off9 crest WAV relative or new d person audxxt g cremation: (Name) �— (Address)Relationship to the deceased Name of Funeral Horne IMPORTANT: represent that to the best of my knowledge,the deceased(ties)or pacemaker,defibrt7ator,battery,battery pack,power cell,radioactive implarrt or radioactive device in his or her body.(C ) i certify that 1 have full power and authorization fo arrarge for the cmm dw 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 prated,defend and save harmless Pine View Carema cum from any and all n'i q and demmrds for lose or damapes which may be made against then► by reason of or connected with the cremation of said remains as dialled.whether such damns or demands are or are not wholly groundless,false or haudulent (Witness) (Address) (S' n AfRehW�AWweo�rL�eZgalpr Representative) Signed signed on this data. 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