Locke, Steven TOrTIN OF QUEE9\�5OUr
PWE VTEW CEMETERY AND CREMATORIUM �y
Qt3'hKER ROAD, QtEENSgLrRY NEw PORK 12804
(518) 745.4476 (518) 745*•4477
Funeral Director kC(7
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Date Of Cremation C)J �U
Time Cremation Started
Time Cremation Completed 40
Type of Container C ��r �d�r
Remarks
12 `3 0
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4521
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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 undersi9red requests and authorizes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
(Name)
( ) (City) ��� ( e) (Zip Code)
who died on day of--�-'= �-CZ
(Place)
Name and address of nearest WAN relative or name of person authorizing awnation:
P b�N1oThr-ti G3 Cou�x�y 12T< - • .P282�.
M) (Address)
Relationship to the deceased
Name of Funeral Home ��/
IMPORTANT: pamnalt
i represent that to the hest� ,the deceased
device in his body.
(« ) �.de>ibriNator,battery,battery Pam•Per
cap,radioactive i nplent
or I certify that I have fu1 power and atdhoftation ro WOW for the aerrnetion of the remains and to direct the disposition of the
cremated remains,that any personal pos'rsssions ttave ellher been removed or may be destroyed.and agree to protect,defend and
save harmless Pine View Crerrnabrium from any and all chins and demands for loss or damages which maybe made against them
by reason o a connecied with the ownetion of said reataits as dkeeted.whadter such Gains or demands are or are not wholly
f
Witness) )
U tea-- i?tea
(Signature and Address of Relative or legal Rom)
Signed on this data.
Disposition of Cremated Remains
I hereby direct pine View CranWM r W to dispose of the cremated remains as f01l0Ws:.
Mail to
Other arrangements-Please specify:
if purivertabon of cremated remains is requested,Gnedc here
Revision:Apr#18,2007