Clawson, Gaylord OF QUEE9�50u
PINE VIEW CEMETERY AND CREMATORIUM
�y
QUAKER ROAD, QUEENSBURY, NEW YORK 128N
(518) 745-4476 (518) 745'-4-477
' Funeral Director My��
Fame C(cvS",�
Case#
Date Of Cremation
Time Cremation Started �h
7�30
Time Cremation Completed t
O •, cep
Type of Container C,a�e
Remarks
MUU� y i 1 h
r 10'00 An
• I
---------------
--------------
I
• I
I
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road.Queemdxuy, New York, 128"
Cemetery Office:(518)745-4476,Crematorium: (518)745-4477
Audi teadw to Cremate
The undersigned requasis and autxxtws Pkw Vlaw G rerrrelorhxn,in axordernce win end aibJerx to is Rules and Regukdorw to
cremate the rerrrakna of
(Narrw) (Sad
O (ter) (Swe) (p coft)
who dad on 2 3 At day of 20_?A
at SawM11-z t-:) 1�ooIW
( ) 0Akkeea)
Neme and addr1s of nearost flrrhg relative or rw a of person sulhod&v cremation:
JrAAJ, T �--tAW501,1 F0 SOX hy9l4ed OF
(Name) (address)
Relationship to the deceased WI FF—
Nerve of Funerd Home j"1U-EA )qW EPq 1- y�"'►F
IMPORTANT:
i represent that to the beat of my Ionowletlge.the deceased(1 w)or( q)pecemelm.deftrllloor.betlery.betlery peck power
cell.rodioacdm implant or redloactive device in Nis or her body( )
I certify that I have to power and suftwbadon to arrange for the cremation of dw rernakw and to disc-the ding oellic of the
cremated reme4is,that any personal p m a e 1 ions have sillm been rerrnw s or may be dssuoyed,and agree to prolsct,defend and
saw harmless Pkw View Cremswrian from any and ell clef ,and demands for low or damages which may be made against them
by reason of or oorrrwcied wpn the ctien adn ol said remelrw as A oft d.whelher such steins or demands are or are not wholly
or ireudLdwL
p✓I/ ��
ag;�
(Wltrnsss) (address)
T
Signalrse and Address of Relative or LOW Representative)
Signed on this dale: �Q lZ3 f 0
Disposition of Cremated Remehs
I hereby dkea Pine View C nretorim to dispose of the aertteled renteirs as folowe:
Mei to
Other wrwVwnwft-Please Opacity:
If pulvertwtion of cremated rernehw is requeeted,clnedc two_tef
Revision:April 18,2007