Crannell, Lillian OF QUEE9�5oU
PINE VY
E�' CEMETER qMj CREMATORIUM1
Y
QUAY-F—R ROAD, Q AN
' NEW YORK 12804
(518) 745.4.476
(518) 745••4-477
Fame Funeral Director
Gate Of Cremation Case#. U�3
r 2�
Time Cremation
Started ' lv
7 '.me Cremation r
Completed 3y-2�
Type of Container
Remarks
h
4 33
Town of Queensbury
Pine View Cemetery and Crernatoriutn
21 Quaker Road, Queensbury, New York, 12804
Cemetery Office: (518)745-4476, Crematorium: (518) 745-4477
Authorization to Crernate
The undersigned requests and authorizes Pine View Crernalorium,in accordance with and subject to Its Rules and Regulations to
cremate the remains of: n
(Name) (Sex)
&.2
(Street) (City) (Stat6) (Zip Code)
who died on �-/ day of
at GIENS f4- 11S /7e►S�i Ar IF SF�iis_- _-_ /_ __
(Place) (Address) -
Name and address of nearest living relative or name of person autlxxWiV ctematkxt:
�'c�7`fibE2�- &Z ,Sbc-ew ,,v AV -
(Name) (Address)
Relationship to the deceased Aa ibe yrY• ��__.— --_
Name of Funeral Home Ku�/✓��TqN 1V i 4L4—A19'u '- ee tf
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(ties no)pacemaker,defitxillator,battery,battery pads,power
cell,radioactive implant or radioactive device In his or her body.(Circle One)
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
gro false or fra ulent.
Ntess) (Address)— --
1
(Signature and Address of Relative or Legal Representative)
I
Signed on this date: !ZA /dg _------- ----
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify: --- -—
If pulverization of cremated remains Is requested,check here _
Revision:April 18,2007
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