Pedersen, Beatrice 0 F QU E E 9�,-5 3 Ur��
PINE VIEW CEMETERY AND CR
QVAXER ROAD, EMATORIUM
QUEENSSURY, NEW YORK 12804
(518) 745.4476 (518) 745.4477
Fun Director i3REwe(:
Fame
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Date Of Cremation 1
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Tame Cremation Started
Tame Cremation Completed Gj; 30
Type of Container r
Arel cArd C /'
Remarks
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1
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 C108179 to
The undersigned requests and adzes Pine View Crematorium in accordance with and subject to its Rules and Regulatbm to
Cremate on rem;**of: _
' % .D66//
who dr on of 20Og
at Pam) )
Now OV address of or name of person c�erntatbn:
(Ti
Rela*w*M to the
Name of Furtenal Home
IMPORTANT: the deceased(has)or(has no) de�d18W or Wy other beWy operated
i represent ittat 1D the best of my IvtartAedBe,
device In his or her body. (Cirde One)
I oa*Uld 1 have full power and sAwrization to arran ga for the ownow of the remains and to direct the disposition of the
txemated remains,flied any personal possessions trove elttrer been removed or may be destroyed.and agree to protect,defend and
them
save harmless Pate View Crmrretor�n from arty and deims and demands for loss or damages v�nvey be made agett>st
by reason of or corrected w8h the of rerrtafra: ,vrttettter such dabtts or demands are or are not
wholly
grou,dles%false or baudulwit
(Address)
( Rob"or Legal Represertative)
Signed on this date
Dspoom of Cremated Remains
i hereby direct pme View Crematonum to dispose tithe cremated remains as MUM.
Mail to
Other arrangerrerits-Pleam SPOCIfr•
if pulverization of cremated re Wns is mWested,dtedc bete
Revision:January 1.2006