O'Connor, Jean OF
PINEQUEE9�SB
' IEYV CEMETERY AND CRE QUAKER ROAD, QUEFINSBURY MATORIUM
(518) 745.4476 NEW YORK 12804
(518) 745••4477
Funeral Director
ame
DaCe Of Cremat Case#
ion �$
T ;me Cremation Started
Tame Cremation Complete
Type of Container
Remarks
OR
Town of Queensbury
Pine View Cemetery and Crematorium
21 Chok r Road,Queensbury,New York, 12804
Cemetery O(fiw.(518)745-4476,Crematorium:(518)745-4477
Authorization to Cremate
The undersigned requests and authorizes Pine View Crematorium,In accordance with and subject to its Rules and Regulations to
create the remains d:
(Name) (set
ao Mc au-yhuu l nS W 124o I
(Street) (City) I (State) (Lip Code)
who died on day of C 20fA
at CIA Qf1S JQQ a .L..IC 10\4 1 Z 40A
( ) "Cidress)
Name and of merest filling reWm or named person std orizft cremation:
(Name) �l
Relationship to the deceased k I �n�
Name of Funeral Horne"CLk-A X'1A-a , (Sal -CC E
Al-
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has no)paoernalmr,defibriWOr,battery,battery pads,power
can,radioactive implant or radioactive device In his or her body.(Circle One)
I certify that I have full power and authorization to arrange for the creandw of the remains and lo direct the disposition of the
cremated remains,that any peraortaf possessions,have either been noted or may be destroyed.and agree to protect,defend and
save harmless Pine View Cremaloriurn from any and as claims and demands for loss or denteges which may be made against them
by reason of or connected with the cremetion of said as direciad,winew such deists or denherds are or are not wholly
grocxdless,false '
(Signature and Address of Relative or Legal Representative)
Signed on this date: 4q�07
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