Goldman, Lucy o
t
rrO O
PU`lE QUEE9�-
S YT
Ems' CEMETERY AND CRE
QUAKER ROAD, QUBENSBURY MAT,
(518) 745.4476 NEW YORK 12804
(518) 745*•4.477
Funeral Director
game uc (u� ( C .
Date Of Crematj.on Case#, /tU
T ;m
e Cremation Started
50
Tame Cremation Completed
s 46
Type of Container (�644rc��
IST
Remarks
z,,)
- ---------------
--__
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury,New York, 12804 ,
Cemetery office:(518)745-4476,Cremat(rium:(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
cremate the remains of: f
_ ) ( )
MUM
(fit) (City) I (State} (Zjp Code)
who died on Yam_ day of 200L) (Address)
at ",lot
iplace
Name and address of newest Crving relative or name of person authorizing aeeotion:
O (Address)
Relationship to the dew
Name of Funeral Home '" • N
IMPORTANT:
I rapmsant that to the best of my calf,radioactive implant or radioactive devioe, dec the eased�(Circle One) o,defibripato,battery,battery .power
I candy that 1 here full power and authorization to erranpe for the aemation of the remains end to direct the disposition of the
cremated remains,that any personal possessions ellim been renraed or may be destroyed.and agree to protect.defend and
save harmless Pine View Cm"Moglum_ may
by mown of d aen edon aid remains asdeck,vdv*er such cis ms or demands are or are not wlwMyy
gmu ndless,false or fraudulent-
(S' re and of elative or Legal R )
Signed on this date: /
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,chat*here
Revision:April 18,2W7