Samter, Marie TOWN OF QUEENSBURY
Pine View Cemetery and Crematorium
27 Quaker Rond, Queenshtrry, NY. 72804.5902
(518) 745.4476 (518) 745.4477
hirP://wNv%v.queensbury.net
Funeral Director: K
Name of Deceased:
Case Number: j
Date of Cremation:` S - vq
C,
Retort: Aw��,�� Sl C ,SE
Time Cremation Started: 1. 3 o AM
Time Cremation Completed:
Type of Container: `hrtj t�vtr
Remarks:
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" Home of Nnturnl Benuty ... A G0011 Plnce to Live "
ICB
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbur'Y, 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 ot:
AM I 1r u/S �eM .eZ&-
(Nam) (sex)
2 Win- � �� � t / Z��.
(Street) (City) ( e) (Zip Code)
who died on day of 2O-a2
at
(PISIM)
Name and address of nearest relative or name of cremation:
/Li T 8 ` .
(Name) j�� (Address)
Relationship to the deceased \ ' ` Q",
Name of Funeral Hmeo
IMPORTANT: -�-�,_
I represent that to the best of my knowledge,the deceased(has)a n°�maker,def llator,battery,battery pack,Power
cell,radioactive implant or radioactive device In his or her body.(CIrde One)
I certify that I have fire power and mavrization to arrange for the crerrretion of the remains and to direct the disposition of the
cremated rerrWe,that any Personal possessions have enter been reproved or may be destroyed,and agree to protect.defend and
save harmlass Pkte View Crenuftriurn from with said remains drecled,whetter such claims or demands are or are not whollyy
nd ae claims and demands for loss or damages which may be RVKW against them
by reason dr
� . may. �goy
(Vyi1r>ess (Address)
(Signature and Address of Relative or t egal Representative)
Signed on tlus date:
I
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mad to
Other arrangements-Please specify:
if pulverization of cremated remains is requested,check here
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Revision:April 18,2007