Marcotte, Roland puYE .J QUEEN,5tBUr
VIEW CEMETERY ANID CRE
QUAKER ROAD, QUEp.NS$URY MATORTUM
(518) 74S•4�76 �W YORK 12804
(518) 745.4477
Funeral Director
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Oa t e Of Crema t i.on .3 Case#
Time Cremation Started ZW
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T :me Cremation CompleC d
Type of Container 'I
Remarks 15T
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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
crerpqte the remains of:
�L j.
(Name) (sex)
30b 6 1 L, 'c
(Street) r,d (City) (State) (Zip Code)
who died on j day of `).._ \20
at c9 I.�,� o r. V: of �
(Place) (Address) —
Name and address of nearest living relative
/orr name of person\auutthorizin'g/cremation: , 4
�Jcl r 5� Cl/ C!� rTr V;^re/� LAC
(Name �` (Addy )
Relationship to the deceased _s— :^\
Name of Funeral Home 2�IMPORTANT:
I represent that to the best of my Iv�e,the deceased(has)or no)pacerttaker fibrittator or any other battery operated
device In his or her body. (Circie 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 possesslons have etcher been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View Crematorium from any and all claims and demwids for loss or damages which may be made against T em
by reason of-or connected wttti-the-crernation of said remains as directed,whether such claims or demands are or are not wt-"y
grou t, _
(Address)
L2A Al
( nat re and r of a or Legal Representative)
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as fellows:
Mail to
Other arrangements-Please specify:
If pulvertzalfon of cremated remains is requested,check here
Revision:January 1,2006