Heath,Harold TOWN OF Q UEENSB UR Y
Piue View Cemetery nud Creutntoriun,
21 Qunker Rond, Queenshury, N.Y. 12804.5902
(518) 745.4476 (518) 745.4477
hirp:iiww%v.queensbury.net
Funeral Director: e tin
Name of Deceased: �le
� c
Case Number: Z '
Date of Cremation: ►`I 3 2005
Retort: ow r
Time Cremation Started:
I• Z
Time Cremation Completed: Z 100
Type of Container: ���I (A rc,
Remarks:
" H0 "ne O/ Nnturnl BenutY .,. A Plnrr tO Lour "
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
creme a the r�7 offt� E
(Name) Sex)
(Street) (City) ( e) Rip/�
who died on day of 20v
at G
(Place) I (Address)
me and address of nearest living relative or name of person autliorvJng cremation:
(Name) }(Address)
Relationship to the ��0 1
Name of Funeral Home
IMPORTANT:
1 represent that to the best of my knowledge,the deceased(has (has no)pacemaker,defibrillator,battery,battery per,per
cell,radioactive implant or radioactive device In his or her body.
I certify that►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 connected with the cremation of said remains as directed,whether such claims or demands are or are not wholly
groundless,false or fraudulent.
(Ws) ( )
(Signature Relative or Legal Representative)Relative or Legal Representative)>
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,check here
Revision:April 18,2007