Girard, Bonnie pWE •J QUEEN�513U(�y
VIEW CEMETERY AND CRE
QUAKER ROAD, QIlEgNSB(1RY MATORIUM
(518) 7 ' NEW PORK 1280a
45.4476
(518) 745•4477
.Funeral Director C H J
Name
Case#.
dI te Of Cremation
Time Cremation V f UO �
Started ;��
T ;me Cremation Completed
Type of Container �
Remarks tO�,ar N
L/F Z 'i u Ph
i
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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: G-wox lI
(Name) (Sex)
1 ��
5 C"s61, �-1 � I hU
(Street) ,, t-1 (City) ) (State) (zip Code)
wh9,died on v day of ( L 20
.(.P164.S GaS Ji�a.� 16a ��• Q� �d i8, 1.�`� tom(
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
rn(c�y-' h, i rc' �d
(Name) (Addy
Relationship to the deceased J-)Lis
Name of Funeral Home SIG
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or has pacemaker,defibrillator,battery,battery pads,power
cell,radioactive implant or radioactive device In his or her body.(C'
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 agairut them
by reason of or connected with the cremation of said remains as directed,whether such claims or demands are or are not wholly
groundless,false or fraudulent.
rtness) 'Address) j
/'
(Signature and Ad&ess of Relative or Legal Representative)
Signed on this date:
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Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
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other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
Revision:April 18,2007