Tidriksaar, Ilmar f
�O OF QUEE9�5OU(�y
PWE VIER' CEMETERY AND CREMATORI
WALKERhKER ROAD, QU UM
BENSSURY, NEW YORK 12804
(518) 745.4476 (518) 745•-4-477
Funeral Director
_���E�
Name
`- ' i (c�tli� 5�tif _ Case# h3t
Dace Of Cremation A;,�,•�
Time Cremation Started
Time Cremation Completed 0
Type of Container
c2 tc Lo Ct. �� �,(4
Remarks
Am
---------------
i� 30
4 53%
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 aufhortms Pine View Cramatorkxn.in accordance with and sLMw to its Rules and Regulations to
cremate the remains of
(Sex) �z�
(city) ( e) (Lip code)
( ) 2-3
day Of /t► )
who died on
(Place)
at (Address)
Flame 7 address of nearest Wing relative or name of Person authorizfg cremation,
n
O C r
Relationship to the deceased
Name of Funeral Home
IMPORTANT: the deceased(has) no) maker,defibtiNator,battery,battery Pmi1ef
I represent that the best device
in his or her body-
oell,radioedive rnpla�rd rrsdioecM
I om*that 1 have U power and macrf�ion to arrange for the cremation of the remains and to direct the deposition of the
cremated remains,that any personal possessions have eldw been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View crematorium from any and 811 c N, I and demrerds for toss or damages which may be made against them
by reason of or connected with the creme Lion d said remeins as directed.MAna w such cieirns or demands are or are not wholly
groundless Was or*wjduWt ;
of R Or LegaI1L`y/7J,tTReW6)
signed
on this data: J/ /Z [6
Disposition of cremated Remains
I hereby direct Pine View CrarmmAu m to dispose of the cemated remains as faUows:
Mail to
Other arrangements-Please specify'
if pA izatw of cremated remains is requested,check here
Revision:April 18,2p07