Leavitt, Laura i t
TOWN OF Q UEENS B UR Y
Pine View Cemetery and Crematorium
27 Quaker Ronal, Qneenshury, NY. 12804.5902
(518) 74 5-44 76 (518) 745.4477
httP://wNv\v.queensbury.net
Funeral Director:
Name of Deceased:
Case Number: Z
Date of Cremation: h Z 1003
Retort: � r�
Time Cremation Started: 0
Time Cremation Completed: `�'.SS
Type of Container: 4%r.I p4 rc
Remarks:
IN Ts() ,AM
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" Home of N a I o r n I Beauty ... A G001f Place Io 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 remains of:
LaLo—CL T '-eC"v 1-�.' -�e rv,c t e-
(Name) r (Sex)
C�L l 4 2. 1-c r l F:U>CL Yt4
(Street) (City) (State)' (zip Code)
who died on Its s day of r 20A
at _Glen, s a
(Place) --�(Address)
Name and address of nearest living relative or name of persona cremation: _
Dr.�v ► � Lewv tt- ->`5 Ot C'o'u,c\
(Name) \ (Address)
Relationship to the deceased 11 U SV-)G n ci
i
Name of Funeral Home 1�1'11 e'r kuX ey- 6111 e
IMPORTANT:
represent that to the best of my knowledge,the deceased(has) )pacemaker,defibrillator,battery,battery pack,power
call,radioactive Implant or radioactive device in his or her body.( )
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 connected with the cremation of said remains as directed,whether such claims or demands are or are not%holy
groundless,false or fraudulent.
$Address) J66L 4 d
(Slg to and Add
ress of Reladve 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:
Mall to
Other arrangements-Please specify:
If puNerization of cremated remains is requested,check here
Revision:April 18,2007