Clothier, Beatrice �O O
F QUEE9�5�Bur
PWE VIEW CEMETERY AND CREMATORIUM
�y
QUAKER ROAD, QUEENSgURy, NEW YORK 12804
(518) 745.4476 (518) 745'-4477
Funeral Director
Name �j JI f
Case# L
Date Of Cremation
KII 0-a r f Z
Time Cremation Started
7'
Time Cremation Completed 9AD
TYPe of Container
Remarks
9
V�-
r � sz7
Town of Queensbury
Pine Yew Cemetery and CrematDrium
21 Quaker Road,Queensbury, New York, 128W
Cemetery Office:(518)745-4476,Crematorium:(518)745-4477
Authorization to Cremate
The undersigned requests and aulhonzes Pine View Cremaiarkim,In accordance with and subject to its Rules and Regulatlom to
cremate Joe remains of:
?2lG,E CGErr-���-2
(Name) (Sex)
:7FnAa a zo P i Fear lU , 1 . aA U l k'i I �.
(Street) (may) (State) j (Zip Cade)
who died on I day or iU �S 2oQ
! at �t n s� \f r ) u r`s�QQ omP
(Place) (Address
Nam��and address of nearest living reiatim or name of person authorizing cremadon:
(Name) (Address)
Rutlatlonship to the deceased SD Y1
Name of Funeral Horner—f
IMPORTANT:
I represent that to the best of my knowledge,the deceased(hes)or Qnoopacemaker,datrbriliatm,battery,battery Pack,Power
cell,redioe�im implant or radioactive device In his or her body.(Cirde
1 certify that 1 have full power and authorlmit on to arrange for the cremation of the remains and to dked the disposition of the
cremated ramaim that any peraonei possessions have either been removed or may be destroyed.and agree to Protect,defend and
save ihermi ss Pine View crametorkirn from any and all claims and demands for loss or damages which may be made against them
by reason of or converted with the cremation of said murrains as dlreuied,whether Stich claim or demands are or are not wh Wily
less,false or fiagdhlerht
(wmtess) (Address)
Signature Address of Relative 1 Representative)
Signed on this date: 4f4!!L'6
Disposition of Cremated Remains
I hereby direct Pine View GrepmeDorium to dispose of the memeted remains as follows:
Mao to
Other arrenpements-Please spew.
If pulverization of cremated remains is requested,check here
Revision:April 19,2007