Lamb, Lawrence OF
PWE YI QUEE9\�5oUTry
EW CEMETERY AND CRE
QVA-Y� ROAD, QUEENSSURy MATORIUM
(518) 745.4476 NEW YORK 12804
(518) 745*-4.477
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Funeral Direct I:
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Date Of Cremation Case
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Remarks
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury,New York, 12804
Cemetery Office:(518)7454476,Crematorium:(518)745-4477
Authorization to Cremate
The undersigned requests and authorises Pine View Crematorium,In accordance with and subject to Its Rules and Rtions to
cremate the remains ot:
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l�17 TC ��Lr
(Nam) (Sex)Aj� (Sex)
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(sheet) (City) �_. ( ) (Zip Cam)
who dW on /3� day of 20joe
(Place) O
Nerne and address of neerast Wkv or name of person scion:
(Name) (Address) / v
Retetionship to the deceased L'e ,1-5 /�
Name of Funeral Home J / ) ► �v� / U J�C. /7 C y✓�� N
IMPORTANT: �'��
I represent tttat to the best of my knowledge,the deceased(has) maker.detbrlwator,battery,battery pack,power
cell,radioactive Implant or radioactive device in his or her body.(fide )
1 certiry that 1 have ful power and a dwrkBdon 10 arrange fa the creimMon d the remaits and to direct the disposition of the
cremated remairm that any peraarre!posseasiorts here etiitar been rerrtoerad or they be destroyed.and spree to protect,defend and
save Pine Vkew Crenrtelodum from any and a8 calms and dennetds tar hm or dern ago a wA*:h vW be made agaitst diem
by reason br with the caemelion d said remains es di ecied.tMmdm such damns a demantde area are rtot wholly
or
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(SWwture andAddress of R Legat Representative) / L
Signed on this date:
Disposition of cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remetns
Tb / ill
Man to S �}
Other arrangements-Please specify:
it pulverization of cremated remains is requested.dteck here
Revision:April 18,2007