Beaty, Douglas OQUEE9�5OUI�y
PLNE SEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURy, NEW PORK 12844
(518) 745-4476 (518) 745-4477
Funeral Director_
•game I �y• �5 n
C a s e# _ Z
Date Of Cremation
Time Cremation Started Q") vo A
Time Cremation Completed 10 :+o
Type of Container urr hf� Cra�f�-d
Remarks
MAIM
io io
57
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury,New York, 12804
Cemetery Office:(518)745-4476,Crematmium:(518)745-4477
Authorization to Cremate
The undersigned requests No W#wtws Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains ot:
I�ouGI �1r!IYNEE- 11,11 �)EA-7 MAIr_
MOM)
I6 ri��dMA2 D2u �.>� r Y) �C�)
(street) � (crty)
who died on a day of�1 U J ZO O
at Al v �y
(ate)
Name and address of nearest*AV relative or name of person atrltwrt&g aematiort:
S► I l PQ r M�,�u /�5���,�,�.� /ti �A�v,��'ya�2r!(��`a�3 i
(Name) (Address)
Relationship to the deceased
Nam
Na of Funeral Home
IMPORTANT:
I represent that to the treat of my W*wledge,the deceased(has)_ (has no) master,de6bbe"ator,battery,be per•Power
call,radioactive implant or radioactive device in his or her body.(C
i oerMy that 1 have toll power and autitorb2don 10 arrw for"aenation of the remains and to direct the disposition Of"
cremated rerrtws.that any personal Pyre ton~been remtaved or may be destroyed,and spree to protect,defend and
saw
by reason mW wo"cr w emsina dbe w ng = d dch greet so not mAyy
or frauddent.
_ /h 4i C . , M7 fZ83(
(witness) (Address)
�.
(Signature and Address of ROOM or �)
signed on this data.
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Plesse speciN:
If pulverization of cremated remains is requesters.check here
Revision:April 18,2007