Balciunas, Anthony .L. O
P W E YY E 4Y QUEE-�(Bu
CEMETERY AND r�
QUAD g ROAD, QUEEgS$ CREMATORIUM
(518) 745.4476 URY, t`!EW YORK 17804
(518) 745.4.477
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Funeral Director 5`IA FO�v
date On Case
Time
Cremation Started
T �e.
T Cremation Completed 1Z' 3U
r ?e of Container rr Qh'
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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 undarsigned requests and authorizes Pine Vlaw Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
(!dame) C E
f8f'i/i ytJ e( 3 C'
(50
)'�' (CA ) (S t b te) (7pCode)
who died : , r
�{" •' • day of C_TcB BE R 20 If
at C1LI; ��LlE6 (\lS
(
Address
Name and address of nearest living relative or name of person authorizing cremation:
cNeme� L N S c - = -cam ��;n 1 a g g
( )
RelationsNp.to the deceased
Name of Funeral Home -s--�4'aprF0 R
IMPORTANT:
I represent that to the best of my Wowledge,the deceased(has) (has rro maker,defibrillator or any other battery operated
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 sold remains as directed,whether such claims or demands are or ere not wholly
groundless,false or fraudulent.
- �S �(A 1.�A-VERFwPD,"Y) ( '�I�S�
Witness) (Address)
Z— --4��- - !�E�
r< <
(Signature and Address a five or Legal Representative)
Signed on this date:
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 pulverbstion of cremated remains Is requested,check here
Revision:July 7,2004