Wood, James 3.
1
TOWN OF Q UEENS B UR Y
Pine View Cemetery and Crematorimn
11 Quaker Road, Qneenshnry, NY, 12804.5902
(518) 745.4476
h,IPJ'w%v%v.queensbury.nC1 (518) 745.4477
Funeral Director:
6 �ll►�r
Name of Deceased:
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Case Number: 2�
Date of Cremation: tq Z
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Retort: —ij owt P., ..,
Time Cremation Started: SG
Time Cremation Complet I0 : ►5
TYPe of Container: a r oyr�
Remarks:
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" fi0 /ne of Natural Beauty ... A C; Ooll Place to Live "
Town of Quee , ry
Pine View Cemetery alld Crematorium
21 Quaker Road, Queensbury, New York, 12804
Cemetery Office: (518) 745-4476, Crematorium: (518) 745-4477
Authorization to Cremate
The undersigned requests and autt*rtzes Pine View Crematorium,In accordance with and subject to its Rules and Regulations to
cremate the remains of
(Na ) (Sex)
CAJ
(Street) (City) (State) (Zip Code)
who died on V1'1 "`7 day of a 20 y
at
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
(Name) (Address)
Reiabonship to the deceased
Name of Funeral Home M R K i t mP r FLnPra 1 Home
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her body.(Circle One)
I certify that I have full power and author¢ation to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,that any personal possessions have either been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View Crematorium from any and all claims and demands for loss or damages which may be made against them
by reason of or connected with the cremation of said remains as directed,whether such claims or demands are or are not wholly
groundless,false or fraudulent.
(Wrtness (Address)
(Signature and Address of Relative or Legal Representative)
Signed on this date: Cam-/ ;? ' 0 �S
I
I
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the Cremated remains as follows:
Mail to
I
Other arrangements-Please specify:
If pulverization of cremated remains is requested,Check here
Revision:April 18,2007