Peters, Marion r-ro OF
W QUEE9�,(5(3Ur�.�
PINE VIEW CEMETERY AND CR
QUhKER ROAD, � EMATORIUM
QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4-477
.dame
Funeral Director_ C
N �r } �11,01
Case
Date Of Cremation 533
Time Cremation Started
T ;m � ZS
e Cremation Completed
l r• 30 �
Type of Container n
remarks ,
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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) 7454477
Authorization to Cremate
The undersigned requests and authorizes Pine View Crematorium,In accordance with and subject to Its Rules and Regulations to
cremate the remains of:
IuJgr' �• t s F
9e)2Ll,1Ylu fncGl%tcl 0'k'e-a (Sex) ---
(Street) (City) (stale) (zip Code)
who died on 1.04 day of 10.P&
at G& • u ►dl• Ge+z C0(utlyt4
(Place) (Address) --—
NC,and address of neat living relative or name of person authorizing«ematkiii:
(Name) (Address)
Relationship to the deceased,
Name of Funeral Horne Q�t,yti,fti.�..Q�1 I r�4kavt,, O
m VtL)d cyUW -t fyUM�--
IMPORTANT: ,
1 represent that to the best of my knowledge,the deceased(has or(has no maker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device In his or her body.(
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 of damages which may be made against them
by reason of or connected with the cremation of said remains as directed,whether such claims or demands are or are not wholly
groundless,false or fraudulent.
(Witness) (Address)
2e
(Signature and Ac ess R-Relblivd Ortegal Representative)
Signed on this date: lrf[6�6 _
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify: --6 If pulverization of cremated remains Is requested,check here V"'_
Revision:April 18,2007