Teresi, Michael OF QUEENB
Try
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSgURy, NEW YORK 12804
(518) 745-4476 (518) 745.-4477
Funeral Director_ Ig Rj
.dame
Date Of Cremation (j(7'- O
06
Time Cremation Started
jl,uo AM
Time Cremation Completed Z:oo fly
Type of Container CAs �Pt
Remar'Ks
1110
,1d
Ego Z:coo n
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Oct 16 08 03: 29p Gtble Baronick Funeral He 814--371-1628 p. 3
47g
Town ofQueensbury
Pine View Cemetery and Crematorium
Quaker Rcad, Queensbury, New York, 12804
-�emet :y Office: (518)745-4476, Crematorium: (518) 745-4477
Authorization to Cremate
The understaned requests and F Lnorzes Pine View Crematorium, it accordance with and subject to its Rules and
Regulations to cremate the rem; rs of:
4^
(harne) (Sex)
istreet) (City; (State) (Zip Code)
JCr. t
rr`,o died un f J _o y,i _ 2008
{Place (Address)
Narne and address of nearest lip. is eiative or name of person authorizing crematior:1`1 G ti• 'T (��'•�:A`G -/4'.t., V H`1 t.i 0,�+• I l;, �l
Relationshic to the deceased W'r
IMPORTANT: r
i represent t'jr t t,t ie best of my k-o rledge,the deceased(has)or!.s n >acemaker,clef ibrila'or er any other battery:perated dev ce iri his or h-r
bony.(Circle One)
nerbly ihu-.l have full pourer and authorization to arrange for the cremation of the remains and to direct the disposition J the cremated remains,that any
oersonai possessions have eith-r beer removes or may be destroyed,and agree to protect,defend and save harmless Pine dew Crematorium frog
any and al;clams and dertande for loss or damages which may be made against them by reason cf or connected with the cremation of said remains as
directed woether•s ch slat i jdemands are or are not wholly groundless,false cr traudulent.
(Wi ness) (Address) =� G
(Signature a d Address of Re at.ve or Legal Representative)
Signed or this d e r.l. • �r„�<,'t�. 5�) �'`-�- ' ��— ''' --� - ----
aispos lion of Cremated Remains
here,,v direct Pir. ev:CrFinatoricm to disc ise of the cremated rema ns as tollows,
MEil to
Other arrangerri .•Please specify , rf -u era Home will pick.up
Liputver Zaflon-r .�riaT�r"mams €qL :tt cficcY.Tie'ft��-
Revisor:Jan.ia '_OUu