Joyce, Joanne PINEJ QUEE9\�5DUI�y
YTEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY NEW YORK 12804
(518) 745.4476 (518) 745-4477
Funeral Director et
Fame i
C a s e#
Date Of Cremation
v c. 1 3 Z ce
Time Cremation Started /'10 i7
T .me Cremation Completed 3'
Type of Container pp
Remarks 69
20
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Town of Queensbury
Pine View Cametery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office: (518)745.4476,Crematorium:(518)745-4477
Auttwrizetbn to Cremate
The underaipned requests and authorlxes P1rte View Crematorium,in accordance with and subject to its Rules and Regulations to
cream""rem eft at _
(Name) (sett)
4 0 j A.Xff -
(Street) (City) (fie) (ZlP ems)
who died on .i - Id- day d �f�1S _so_.7— ,j
�
E ) (Address)
Name and address of r Hama of person cremation:
JAV
( ►) O /.,
Reiatior a to the deceased CIA Uq
Name of Fun"Home �u WA
IMPORTANT:
I raprasera that to the beat of my krtowiedge,the deceased(has)or(free no)pacemaker,deWliator,battery,battery peck,power
c",radioactive Nnpiark or rad oactive device in his or her body.(Ck*One)
i cw*that 1 have U power and att<aUetlon to arrange for the oven edon of the re rom and to direct the disposition of the
cremated remains.that any perwnW possessiorts have other been rernoved or may be destroyed,and agree to protect,defend and
am Pine View Crematorium from any and all cisims and dementia for loss or damages which may be made against them
by or the qonwtlon d said remai ne as directed,whether such doom or demands am or are not wholly
false or o , 01— Lek+ f 1 1V
K (Address) ��"'
and Address of Ratetive or Leo Representative)
ff n a' /yam
on this date: �{ E dq ro// /✓F 4(�C"_' IL '7d
Disposition of Cremated Remains
I hereby direct Pine View C,rw*Wrlum to dbpose of the cremated remains as knows:
Mail to _ " ---%
Other anwvoments_Plasm spedfy:__
if putverl¢ation of cremated remains is requested,check here ,
Revision:April 18 2007