Daigle, Roland L O O
FPLNE
W CEMETERY AND CRE r �J QVA Ft ROAD, QUEENSBURY, NEWMA� ORjUM
(518) 745.4.476 YOR'K 12804
(518) 745-4.477
.N a m e
\\ Funeral Director "
Can Q ��
Date 0( Cremation Case#
-
Time Cremation Started t,
T : me Cremation Completed '
Type of Container (1 4-1
remarks � .�
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12804
Cemetery Office: (518) 7454476, Crernatoriurn: (518) 745-4477
Authorization to Cremate
The undersigned requests and authorizes Pine View Crematorium,In accordance with and sutAect to Its Rules and Regulations to
crerrh a the rema�s of-
ent
(Name) QI (Sex)
(Street) (City) &- -
(Sttate) (zip Code)
who died on day ofat 'd5's �1 J�1(It m� r
(Place) (Address)
Name and addr of near living relative or name of person th(r' it emat xi:
_J )tfl .e_ lob_6 lar�W W.
�r � rZ�1
(Name) (Addr�)
Relationship to the decea � _j�—�_� . -__-- -------
Name of Funeral Homed t 2 - Q R t�'_-! -t— -----
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has) (Ihas no) maker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her body.(Cr
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 against them
by reason of or connected with the cremation of said remains as directed,whether such claims or demands are or are not wholly
ground",false or fra le_nt,:
gn fur n ress of Relative or Legal Representative)
Signed on this date: �V --- --- - ---- --
Disposition of Cremated Refnalns
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to --
Other arrangements-Please specify:If pulverization pulverization of cremated remains is requested,check here
Revision:April 18,2007