Harsha, David X
TO WYQ OF QUEEN,,593UTy
PUNE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW PORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director_ Mg
Name / � �Cjr-
Case#
Date Of Cremation �JI
Time Cremation Started
Tame Cremation Completed to" lo
Type of Container
Remarks
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Moves �;3v
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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
cr to the remains of:
dui 1�AS, A-
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D o¢ C( t_5 A. V / ?aS9
(Street) J� (City) ( tate) (zip Code)
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who died on _y r' day of 20�
at /
(Place) (Address)
Name and address of rest I ng relative or name of cremation:
&6-y Izi
(Name) (Address
Relationship to the deceased /
Name of Funeral Home r
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)01
has aker,defibrillator,battery,battery pack,power
cell,radioactive imptent or radioactive device In his or her body.(Cir Clete)
I certify that I have tuU 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 agairtst them
by reason of or connected with the cremation of said remains as directed,whether such claims or demands are or are not wholly
groundless,false or fraudulent. v� PRoM
(W ) ( )
(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 Pease specify: - N , CG' l�/-r!l / 6
If pulverization of cremated remains is requested,check here
Revision:April 18,2007