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Bannon, Jeannette r-rn 7IN OF QUEE-�� 523Ur PINE VIEW VIEW CEMETERY AND CREMATORIUM QUA-K.F-R ROAD, QUEENSBURY NEW YORK 128N (518) 745.4476 (518) 745*-4477 _ Funeral Director Name J r V Case# Date Of Cremation I zoo Time Cremation Started T =me Cremation Completed Type of Container Remarks 1"9 t 'Vv lo '> Ah COWL ►�- JS 3LS Town of Queensbury Pine Yew Cemetery and Crematorium 21 Quaker Road,Queensbury, New York, 12804 Cemetery Office:(618)745-4476,Crematorium: (518)745-4477 Authorization to Cremate The tmderslprted requests and atAhorizes Pine View Crematodurn,in a000rdartce with and subject to its Rules and Regulations to cremate the remains of r (Name) (Sex) 1 � lr-- & ( ) (city) (see) (�Code) who died © day of 20.Qe et � (Place) (address) ' Nam nd ads of raga�� relative or �� � lion: P-A rL,4,- t na �c!G G'JL� (fie) ( ) Relationship to the deceased 4!�5-X t Name of Funeral Home fe, IrA!7 o,� IMPORTANT: I represent that to the best of rry bwwledge,the deceased(has) (has nor crier.door,battery,battery pack,power ceN,radioactive implant or radioactive device In his or her body.(C I certify that I have U power and auttarb atlon to arrange for the cremation of the remake 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 re td on of or lwith ent.the of said remake as directed,whether such clekns or demands are or are not wholly or S- (Address) �d (Signature find or legal es6i ftell") Signed on this darts• / 9 l0 Disposition of Cremated Remake I hereby direct Pine View Crernift uum to dispose of the cremated remains as Maws Mail to Other array gentents-Please spew. If ptAverization of cremated remains Is requested,check here Revision:Aprll 18,2007