Westerhold, Alice A
TOWN OF Q UEENS B UR Y
Pine View Cemetery and Crematorium
21 Qunker Road, Q,reenshury, NY. 12804-5902
(518) 745.4476 (518) 745.4477
htrp://wlv\v.queensbury.net
Funeral Director: ��tc
Name of Deceased: l Ic It hid
Case Number: Zcj
Date of Cremation:
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Retort: rc;N, ,r L
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Time Cremation Started: ! p 5
Time Cremation Completed: I0' 3a
Type of Container:
Remarks:
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" Home of NntitraI Benuty ... A Cno ,l Plnre to Liue "
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office:(518)745-4476,Crematorium: (518)7454477
Authorization to Cremate
The undersigned requests and authorizes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate tha remains of:
A' (-I fib' JNSi b1'L 1�b1� (Sex) C�/1t1'f_[
(Name) / �f(/ (` /
Ps— U� i- C U Zbhn1 c , /�j
street
( ) (City (State) (ZP )
S?— day of 20 e
who died onat
Z /Z 'pd
lea-z--
( ) (Address)
Name a yeas of neare�vngrelative ar name of person�' P tZ �iA1y r
(Name)J (Address)
Relationship to the deceased
Name of Funeral Nome "�
IMPORTANT: aker,ddibr ator,battery,battery pacts,po�►'sr
I represent that to the best of my knowledge,the deceased(has) �)
cell,radioactive implant or radioactive device in his or her body.(C
I certify that I have full power and authorbadon to arrange for the cremation of the remains and to drect the disposition of the
cremated remains,that any personal posse's have either been removed or may be destroyed,and agree to Protect,defend and
save haffrdess Pine View CremBUXILIM from any and al da ims and demands for loss or damages which may be made 898W them
by reason 6f or ocxrteged-�th the cremation of said nooks as directed,whether arch dalms or demands are or are not wholly
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(Witness)Jej ( )
(Signature and Address of elative or legal Representative)
Signed on this date: 2' U
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 mere
Revision:April 18,2007