Smith, Katherine f.
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TOWN OF Q UEENSB UR
Pine Virtu Cemetery and Crenrrrloriunr Y
5 18) 745.4476 Quaker Road,
Qrrtenshrrry, NY. 12804.5902
h(rp:i/www•queensbury.ne1 (518)745.4477
Funeral Director.
Name of Deceased:
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Case Number. Z go
Date of Cremation: ,-.
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Retort: �5w
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Time Cremation Started:
Time Cremation Completed: to .0 6
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Remarks:
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
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:.
(Nam&) �-- (Sex)
(Street) ity) (State) (Zip Code)
who died on A6V1�� day of
at �la P—R/�� /�aS �4 /6 C) A s f_
(Place) Addres
Name and address of nearest living relative or name of person authorizing cremations:
411'ZO-A L660ek_ /�2 6 _CN d
(Name) (Addr s)
Relationship to the deceased
Name of Funeral Home Gle ine.
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or as no
pacemaker in his or her body. (Circle One)
I certify that I have the 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 not wholly groundless, false or fraudulent.
A 11Y IJ S j
(Witness) (Address)
(/ ( ignat a of Relative or Legal Rep. and ddress.)
Signed on this date: 2 GO