Cutler, Jean '7"nrP� OF QUEEN,�OUr
PINE VIEW CEMETERY AND CREMATORIUM
QUf.KER ROAD, QUEENSBURY NEW YORK 12804
(518) 745.4476 (518) 745-4-477
Funeral Director Ma.
K IMP
Name "� e�ti �uf� �
Case# 35L
Dace Of Cremation
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Time Cremation Started IV;0v
Time Cremation Completed COI
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Type of Container
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Remarks
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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
cremate the remains of:
v L A N G C �L► �C f� ��nn CAI P .
(Name) _ (Sex)
(Street) (City) (State) (zip Code)
who died on day of vD L`� 20 0
at S S ,Y, Ir n
(Place) (Address) _ r
Name and address of nearest living relative or name of person{01ortzin9 cremation:
O�
z�(�_��P� (Address)
IL
Relationship to the deceased
Name of Funeral Home 6k I1
IMPORTANT:
represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,defibrillator,battery,battery peck,power
oeii,radioactive implant or radioactive device in his or her body.(Circle One)
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 agairtst them
by of or connected w1th the cremation of said remains as directed,whether such claims or demands are or are not wholly
se u'n
(Address
W4W H--i t-Z-
(Signature and Address of Relative or Legal Representative)
Signed on this date: 0 1 [ ZOOS
0-7
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 puNert moon of cremated remains is requested,check here
Revision:April 18,2007