Reed, Lois TOWN OF QUEENSBURY
Cemetery and Crematorium
21 Qunker Road, Queenshury, NY. 1 2804-5 902
(Z:lw (518) 745.4476
h(Tp"wNvw,queensbu (518) 745.4477
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Funeral Director:
Name of Deceased:
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Case Number: Z Z U
Date of Cremation: ZvCj
Retort:
Time Cremation Started: 7:4/6
Time Cremation Completed: 1 70
Type of Container:
Remarks:
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" Hour o/ Nntural BenutY ... A Good Place to Live "
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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
cremate the re Its of:
A to
2 U �� �E 4 (u X)
(Street) (City) (State) (zip Code)
who died on d y of �' %t1i!�
at Rt 1 �F+
(Place) (fir )
Na and address of nee living relative or name of person authorizing cremation:
--JEl�r\1NEkO 1AGL
(Name) (Address)
RelationshiptothedeceasW
Name of Funeral Home `� h'CrAA
IMPORTANT:
I represent that to the hest of my knowledge,the deceased(has)00
(has no pacemaker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her body.(Cir )
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 which may be made against them
by reason of or connecte4moh the cremation of said remains as directed,whether such claims or demands are or are not wholly
ground Ise or u t.
(Witness) (Address)
(Signature and Address of Re Wive or Legal Representative)
Signed on this date: *'
Disposition of Cremated Remains
1 hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:?—MA-0 7b C-U gmw+c-•
If pulverization of cremated remains is requested,check here __
Revision:April 18,2007