Marciano, Anthony •e
,1
TOWN OF QU'EENSBUR Pied Vidt(' Ctatdtery and Cr'einatoriurtt Y
21 Quaker Road, Qtttdttshttry, NY, 72804
018)745.4476 .5902
http:iiwww.queensbury.net (518)745.4477
Funeral Director. Re Q w
QhM
Name of Deceased:
o
Case Number. Z
Date of Cremation: _
Z oog
Retort:
Owl
Time Cremation Started:
05
Time Cremation Completed: 3`�6 P
TYPe of Container:
Remarks:
Z. vo P
z=30
a1�P
" Ho,ttd of Nat itra Bdnttly ... A Goo,t Plnrd I
o Live "
4 2 7G
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, 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 of:
(Name)) n (Sex) l
(� l �cfr l tYr7�13i 4 �� 6;>
(Street) (City) (State) (Zip Code)
who died on /l 0 day of 20_
at C12 11 l d--w))t N��e• /
( ) (Address)
Name and address of nearest living relative or name of person authorWw cremation:
CCrra)
(Name) (Address)
Relationship to the deceased L 3 i �c
Name of Funeral Home
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has) (has no) er,defibrillator,battery.battery pack,power
cell,radioactive implant or radioactive device in his or her body.(C'
I certify that I have 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 and all claims and demands for loss or damages which may be made'agakvA them
by reason of or connected with of remains as directed,whether such claims or demands are or are not wholly
groundless,false or t.
(Address)
(Signature and Address of Relative or Legal Representative)-
Signed on this date:
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 here
Revision:April 18,2007