Dutcher, Floyd OF QUEE9�,-RBur
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PINE VIEW CEMETERY AND CREMATORIUM
QUA-KER ROAD, QLEENSBURy, NEW YORK 12804
(518) 745-4476 (518) 745-41177
[ I Funeral Director_���
Name t (o d vtG�pr
.. C a s e# ZS"
Date Of Cremation f 001
Time Cremation Started —
1' �o
' 'me Cremation Completed
IU� fS
Type of Container
Remarks
S 7Up
/�
4 �1U
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 aut horthas Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
Cremate the remains of:
FIo od- -b.-' t-c trkver I�Gj--Q,.
(N me) (Sex)
Ito 6tU.b(-8 -TefrcSow � S t1�, NJ IZ8CO3
( ) (cay (fie) (gyp ram)
who died on t day of -�LO 20 Qom$
atGCor,sva- lu +4o,.t,4- A iw-';>ojf-LSt.
(Place) --I (Address)
Name and address of nearest Wing retstive or mane of person authortrMg cremation:
n.0 � ail ��-�idyioyJ act•C�u.�_o_nS�,9V� 12`�iC)�
(Nam ) (Address)
Relationship to the deceased
� h }"�
Name of Funeral Home y• .t S^n A c� j6aA-ter
IMPORTANT:
I represent that to the best of my Wawledge,the deceased(has)or(has no)peoemaker.deft"or,battery,bettery per,power
can,radioactive implwt or radioactive device In his or her body.(C irde One)
I certify that I have full power and authorbadon to arrange for the cremation of the remains and to direct the disposition of the
crenated remains.that any personal possessions have either been removed or may be destroyed,and agree to protect,defend and
save harmless View Crematorium from any and all claims and demands for loss or damages which may be made against them
�'a with the crematim of said remains as directed,whether such cJakns or demands are or are not wholly
- 11LaLjdPSfdb YhZ
(Signature and Legm Rom)
signed on this date: S
Disposkion�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 refrains is requested check two
Revision:April 18,2DO7