Clothier, Jean TOWN OF QUEENSBURY
Pine Virtu Cemetery and Crematorium
27 Quaker Road, Queensbury, NY. 72804.5902
(518) 745.4476 (518) 745.4477
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Funeral Director: ! r o tY
Name of Deceased:
Case Number: L.
Date of Cremation:
Retort: L� _
Time Cremation Started: g M
Time Cremation Completed: c' IL{u
Type of Container: 4,.
Remarks:
�N � 3Q • �
• >� IU 4(.1
" Home o/ Natural Br auto ... A G0011 Place to Liur "
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12804
Cemetery Office: (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
crew@, Wthe remains of:
ec," e4 C f/o 'ce :Fe-
(Name) �a C
(Sax)
(Street) / (City) (State) (zip Code)
who died on day of 20 U
(Place) - (Ad�ress
N q and address of nearest living relative or name of person
1autthortring`cremation:1 j
( me) (Address)
Relationship to the deceased
Name of Funeral Horne -�•—
IMPORTANT:
i represent that to the hest of my letowledge,the deceased(has) (has no)�fibriltator or any other battery operated
device in his or her body. (Circle One) ..J
I certify that I have full power and authorization 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 whkh 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
less, Ise ground _.
w 'i a.— ee m e
r ) (Address)
(Signature and Address(5pelative or Legal Representative)
Signed on this date: U U
Disposition of Cremated Remains
I hereby direct Pine View Crematorlum to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:
If pulverization of cremated remains Is requested,check here
Revision:January 1,2006