Moore, Michael ',rya
t
LO OF QUEE9��S�BU2,
PINE V'EYV CEMETERY AND CR
QUAKER ROAD, EMATORIUM
QUEENSBURY, NEW YORK 128C4
(518) 745.4476 (518) 745-4-477
Funeral Director u-2
Name
#.
Date Of Cremati Case NO
on �
T ;me Cremation Started
00
Tame Cremation Completed
Type of Container
Remarks l5t �}5
i4hTti 6�
30 Rho
w
COOL 10' 60Ah
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury,New York, 12804
Cemetery Ofiioe:(518)745-4476,Crematorium:(518)745-4477
Authorization to Cremate
The undetsOW!requests and" tFaes Pkm View CMffm o"n in aowrft a with and subject to Its Rules and Relations to
cremate the remains of:
AAtr hnt-.1 M� �
(Nam)
A L QJ �-� I 1 Qd 1 ncl c. �, �) '� l�S�)
(street) C�77 (CKY)
who died on c5 day of 200.
at
Name and address of nearest Wine refative or name of person aNhoriang«effmW :
(Name) (Address)
Relatfonsttlp w the deceased 1
Name of Funeral Home =tuf
IMPORTANT: dellbrN�Or,bedery,battery Pam•Power
I represent that to the best of my bwwledee.the deceased(has) )Pam•
cell,rediooc i implant or redioective device in his or her body-( )
I ne*that I have tuff power and au0lomi M*M IIo atmWW for the a m Wn of the MM**and W direct the disposition of the
OWWAd remains.that any Personal possessions have ether been removed or may be destroyed,Graf agree to Protect,defend and
save trermless PMO View CM=Mxkm ftm erw mw as claim mw demermis for lose or dmmgw which mW be m8d9 890kw ft"
sold remains as directed,whether such claims or demands are or are not Wwlyy
or ftaudulerrt.
It
(A&Iress)
7/ n
•l (fie and m of Relative or legal Representative)
Signed on this data:
DisposRion of Crerna0ed Remains
I hereby direct Pine View C mneoorium m dispose of the cremated mematrrs as fdW#-P-
Mail to
Other arrangements-Please sPGW.if pulvetzion of cremated remains is requested,cheat here-I
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Revision:April 18,2W7