DeLong, Gail Y
QUEE9 S3
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, EMATORIUM
NEW YORK 12804
(518) 745.4476 (518) 745-4.477
Funeral Director
G1
Ca s e#.Date Of Cremation
Tame
Cremation Started
- i C) /
Tame Cremation Completed
Type of Container
U�`
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Remarks I ST
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#71L;
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury,New York, 12804
Cemetery office:(518)745-4476,Crematoriurrr (518)745-4477
Authorization to Cremate
The undersigned requests and
authortws Pine View Crematorium,in accordance with and to its Rules and Regulations to
cremate the remains of
0.t I J Uc (Sex)
(Nam)
Z I b bar+ 5 F C. �wcL1 d (state) 2 Cup c«te>
(Street)
Of
who died on
at C�Lens �ci lISsP►�a` It�O�a�� T�'E�%O
(Place) (Address)
Name and address of nearest living relolve Or nnanne of person=#Wrizkng owns iorn:
SGU�rt2.
(Nam (Address)
Relationship to the deceased X"h 11 S ^
m2_
Name of Ferai home
urn
IMPORTANT: the deceased(has)or(has no)pacemaker,dellbriMetor,battery,bettery tom,Per
I represent that to the best of my IQno�Medge,
con,radioactive implant or radioactive device In his or her body.(Ckde One)
I certify that 1 have i A power and eullwdn tfon to a nKW jar the aen s*m of the"Mains and to din �to a of th defend and
acted remairns, hat t any personal possessions move eltlner beers r moved or maybe destroyed.
save harmless Pine View CrernneWdLxn from any and ag damns and demands for loss or damages which may be made agektsi them
by reason of or connected with the aemelon of said rnunairrs as dire cited,%boil er such deinrs or demands are or are not wholly
Woundless,f9l9e or kauciLdent. /2
AN
cam)
( ignature and Address of Relative Legal RepreserWW)
Signed on Oft dale:
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 18,20W