Burgess, Cynthia �Q O
F QUEE�Q,BUTy
P'NE "qEW CEMETERY AND CREMATORIUM
Qu"ki ROAD, QUEENSSl1RY, NEW YORK 12804
(518) 745.4476 (518) 745--4477
Funeral Director NT�CE�
Name (, �+� 5
Date Of Cremation
IOU �UUs�
Time Cremation Started
Time Cremation Completed Ill
Type of Container
hill
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)745-4477
Authorization to Cremate
The undersigned requests and authorizes Pine View Crematorium,in accordance with acid subject to Its Rules and Regulations to
cremate the remains of: _
I (Name) �� (sex)
JJ Cal AlrllnY> N/Yj 1c)JD c,-
(Street) —' (City) (State) (Zip Code)
who died on day of N3 L)V . 4-(D3
at e7-)`-1; n I; d —0
(place) (Address)
Name and address of nearest living relative or name of person acdxxt*V cremation:
)or)c, CL1►� ; �cbC ��` r ltio� � L U`�o+�, L
(Name) CC (Address)
Relationship to the deed J D f1
Name of Funeral Home n A , F r c Vy- CCl )}�
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or/`(t>is(►o) maker,defibrillator or any other battery operated
device In his or her body. (Circle One) J
I certify that I have full power and aWrorbstion 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 daans and demands for loss or damages which may be made 89811rst them
by of or connected with the cremation of said refrains as directed,whetter such claims or demands are or are not wholly
fa or haywent.
(W ) (Address)
(Signature and Address of ReftM or Legal Representative)
Signed on this date: 11 ( I ( ? C,C) g
Disposition of Cremated Remains
I hereby tired Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please sir. a I c T-U -t 1,1 ► c-1 -a 1.- h o me
If pulverization of cremated remains is requaded,check here —
Revision:January 1,2006