Burch, Theresa L O
71N
O QUEE9�5
PWE V7E B (_l. r
W CEMETERY
QUAKF-R ROAD, At CREMATORIUM
Q�EN58URY, t'�SW YORK 12804
(518) 745-4476 (518) 745.4477
Funeral Director
Case# �ttq
`ate Of Cremation
Time Cremation
Started
T :me Cremation Completed
2C�
ry?e of Container
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3:!u �h
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbtry, 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) (Sex)
,7 itV16k( �e lea
(fit) ( ity) (fie) (zip Code)
who died on 130YA day of 206
at /&-s ;rCt S gf.L4f i4 too
(Place) I (Address) l
Name and address of nearest living relative or name of person a cremation'
�� 17 M4elb3Are le�si�vj xjv.
(Name) (Address)
Relationship to the deceased K4Z�-
Name of Funeral Home cla 6
IMPORTANT:
I represent that to the best of my Irowledge,the deceased(has oi�)
maker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device In his or her body.
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 from any and all claims and demands for loss or damages which may be made'agakist them
by reason of or connected with the cremation of said remains as directed,whether such claims or demands are or are not wholty
groundlessafalse or fraudulen ��(��w (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