Becker, Lee TOWN OF Q U'EENSB U•R Y
Pine View Cemetery and Crematorium
27 Quaker Road, Qrreenshrrry, NY. 72804.5902
(518) 745.4476
h'rP://www•queensbury.ne1 (518) 745.4477
Funeral Director: k
Name of Deceased: Lec' 113<<I� r"
Case Number: Z
Date of Cremation:
Retort:
Time Cremation Started:
L5'Q
Time Cremation Completed: i : F 5
Type of Container: �,�;� .
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Remarks:
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S%lid
Horne of Nntrrrnl Ben It Y A CioorI Pln � e to
Lrue
Town of Queensbury
Pine Yew 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 remains of: ,n
(Name) (Sex)
(Street) (City) ( *) (Zip ode))
who died on day of
at
(P!cs} (Address)
Name and address of nearest living relative or name of person authorizing cremation:
(Name) _ (Address)
Relationship to the deceased �a�a
Name of Funeral Home --�-�` (�
IMPORTANT: �,battery. y pack,power
represent that to the best of my btowledge,the deceased(h (has(ties)or no)Pacemaker:
cell,'radioactive implant or radioactive device in this or her body.(Chde One)
I certify that 1 have full power and au t fization to BMW for the cremation of the remains and to direct the disposition of fhe
cremated remains,that any personal pow have eOw been removed or may be destroyed.and agree to protect,defend and
save harmless Pine View Crenhatork m born any and al dalins and dermands for loss or damages which ahay be made age them
by reason of or connected with the ciernndon of said remelt as direct,v such damns or demands are or are not wholly
groundlessrfa w fraudulent.
.j - (, o�
(witf;ess) lot ( )' of
(Sig a and / of Relative or Legal Representative)
Signed on this date: y:' , l -�
Disposkion 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 18,2007