Beatty, Carol TOWN OF Q UEENS B UR Y
Pine View Cemetery and Crematorium
21 Quaker Rond, Queenshury, NY. 72804.5902
(518) 745.4476 (518) 745.4477
hicp/iw\vw.queensbury.net
Funeral Director:
Name of Deceased: Clr
Case Number:
Date of Cremation: - ' - all
Retort:
�� C Time Cremation Started:
Time Cremation Completed:
Type of Container:
Remarks:
" Hoare of Noturnl Benuty ... A Goorl Plnie to Lrue "
# I 1
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury,New York, 12804
Cemetery Chive:(518)745-4476,Crematorium: (518)745-4477
Authorization to Cremate
The undersigned requests and aunorfrss Pine View Crematorium.in accordance with and subject to its Rules and Regulations to
crernue thehe remains of_
I , J FPS Lv
(Nam) (sex)
te.. !-- _1-f&L te�'-v Y
(Street) (City) (State) p )
who died on
C, P
day of 20
( )at
E ( )
Name a address of nearest 7rewave or nmme of person ortzing orK
(Name) ess)
Relationship to the deceased a
Name of Funeral Home iL
IMPORTANT: defibriAator,battery.battery pack,power
I represent that to the best of my knowledge,the deceased(has)or(has no)pacBr►►aker•
cell,radioactive implant or radioactive device in his or her body.(C'rrde One)
i certify that 1 have fir!power and wo ort tan to arrange for the crenhatio n of**remains and to direct the disposition of the
aemated remains,that any personal possessions have either been removed OF may be destroyed.and agree to protect,defend and
save hamdess Pine View C emalodtrm from any and ail claims and demerhds for foes ar damages which may be made against tlnem
by reason of or corroded with the aemefion of said remains as drecfed.vrtafar Such claims or demands are or are not wholly
groundless, or f�audukvt
AIC C�fV 31
(Sign ature and of a Leal Representative)
Signed on finis date:
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remaira as fdknws:
Mail to
Other arrangements-Please specify:
If pulverization of cremated remains is requested.dv&here
Revision:Apr#18,2007