Trumble, Dorothy �O O
QUEEg\�5�BU-T
PWEYIE
V' CEMETERY AND CREMATORIUM
QUA,KER ROAD, QUEE.NSBURY
(S 18) 745,4476 ' NEW YORK 17804
(S18) 745'•4477
Director.�'a m e Funeral'�'Date Of Cr Case
emation it, ll3
Time Cremation Started ?Oo
Z� 3S
T ' me Cremation ComPlet d
Ty ?e of Container J
remarks f', N
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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: _
D v�f�w I kum b(e
(Name) (Sex)
S( Cu eeiv Lty- 4?b Syr t 8°` I
(Street) (City) _ Plate) (ZJp Code)
who died on day of S 2007
at
(place) (ems)
Name and address of nearest living relative or name of person authorizing cremation: O
C. TeuA 1710 5f evg_r qre e 1v brY, 4p by-n-y, 1.
(Name) r ((Address)(Address)Relationship to the deceased /�/4 S n JA to d�`�
Name of Funeral Home t2 l4 y r fq it G
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)q (hss no) aker,delibritator,battery,battery Peck power
cell,radioactive implant or radioactive device In his or her body.(C
I certify that 1 have full power and autortretion to arrange for the aemadon 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 Crematorkm from any and 8111 deims and demands tr loss Or damages which maybe made against them
by reason of or connected with the cremation of said remains as dlrected.whWw such claims or demands are or are not wholly
Woundless, or fraudtAert
ddr
r (AN t iv• - qbY jy1�f- i28'Q�
(Signature and Address of Relative or Legal Representative)
Signed on this date:�C�►� .
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other anangerrrents-Please specify:
If pulver¢ation of cremated remains is requested,check here
Revision:April 18,2007