Miner, Helen y
OF
P WE QUEE9\�5OUr
YTE`�Y CEMETERY AND CR
QUAKER ROAD, QUEENSBURY EMATORTUM
(518) 74s-4-476 ' NEW PORK 1280a
(518) 745'-4-477
Funeral Director 5
Fame �
Case# 391
Date Of Cremation
Time ZQ��
Cremation Started
J'Jv 2t,
T ;me Cremation Completed
Type of Container ((6+L Cs
Remarks ra�.� l ZN L �_
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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 Regulatlons to
Atethe remains of:
(Street) (City) (State) (Zip Code
who died on �1 d day of ESL
at <a>='
(tee) (Address)
and address of nearest living relative or name of person aozing ri cremation:
� 1I wrk-�
(Name) (Address)
Relationship to the deceased CxJ-k
Name of Funeral Home c
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has) maker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device In his or her body.(C (has no)
I certify,that 1 have full power and auUrorizatlon to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,that any personal possessions have ether 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 reason of or connected with the cremation of said remains as directed,whether such claims or demands are or are not wholy,
groundless,false or fraudulent.
(Witness (Ad I
ignature and Address of Relative or Legal Representative)
Signed on this date:
4 ZZ
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 puNertmtion of cremated remains is requested,check here
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Revision:April 18,2007
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