Corbett, Rosalie rrn
OF
QUEE��53Ur�y
PINE VIEW CEMETERY AND
QUAKER ROAD CREMATORIUM
QUEENSSi1Fty' NEW YORK 12804
(518) 745.4476 (518) 745-4-477
Funeral Director
Name— (00, �
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Case# 3�7
Da-ce Of Cremati.on
Zoo$
Tame Cremation Started
T ,me Cremation Completed
Type of Container
Remar'KS
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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)7454477 '
Authorization to Cremate
The undersigned requests and autlwtws Pine View Crematorium.In accordance with and subject to its Rules and Regulations to
cremate the remains of:
k0-S'q" lam" l�2 QFr� 1�6�itl�r�t�
puma) (SOX)
A) L6" bn 12,�r
(street) (CRY) ( ) —1 Code)
who died on I -J-1k daY of — 20.0T->
at Q• t= J 1 Z
(Place) O
Name wpd address of VW*relative or name of person
V�/ 4�� `7
(Name) (Address)
Relationship to the deceased
Name of Funeral Home yj "/ JL e t v y
IMPORTANT:
I represent that to the best of my ivrowledge,the deceased(has)or(has no)pecemalw,deftletor,hoary,batter)'pack,power
cell,radioactive imptant or remadire device in his or her body.(Circle One)
I certify to I have U power and mewrbabort to arrange for the cremation of the remains end to direct the disposdlon of the
crertsated remairs.00 any persarral(obsessions tam either been removed or may be destroyed,and agree to protect,defend and
save trarmless Pine View Crenvoorinn f m ON and all chine and demands for lose or damages Nridt may be made against them
by reeson of or co necied wfih tits aenrafl n of said rartaitsAmcb@&vAW1M such deans or damerrds are or are riot wlw/y
false or fraudulent.
( )
and 777�or Legal Rrew
epvtative)
m
siga on tis date:
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Marl to
Other arrangements-Please specify:
if pulverization of cremated remains is requested,Check here
Revision:April 18,2007