Moffitt, George �O OF QUEE9Q5oUr
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PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 128C4
(518) 745.4476 (518) 745-4477
Funeral Director 1e1(Auc��=i?_
Name170
• Case#
Date Of Cremation Npv
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Time Cremation Started_
F,I U{p
Time Cremation Completed
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Type of Container A
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Remarks
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cboL 3;-3007
Town of Queensbury
Pine View Cemetery and C rematoriurn
21 Quaker Road,QueenWx".New York, 12804
Cemetery Office:518-745-4476,C�rC� nv tnt'mr 518-745-4477
Authorization to Cremate
The under signed requests and avthortxes Pine View Cvavaa1onxmxL,m ahem vvdh and subjed to its Rules and Regulations to
cremate the remains(it
George Moffitt Male
(Name) I"t yl 0t;—,I� Ali uG' (Sao
3D-- an d Wevertown, NY 12886
(SUIM) (CI]+) (ate) (Zip Code)
who died on 8th dayof November zu08
at Glens Falls Hospital
(Place) (Address)
Name and address of nearest living reletitre tx cremation:
Juanita Moffitt V, Wevertown
(Name) (Address)
Relationship to the deceased W i f e
Name ot Funeral Kome Alexander Funeral Home Inc.
IMPORTANT:
I represent that to the best of my WwwledW.the deceased(has)of(tias no) �dsfb�. or any oats,'battery operated
device in his or her body. (C"ude(]ne)
I cettif)r that I have tuff power and aut mdzauat ID anarge for the cmmation of the rem and to direct the dis ion of the
cremated remainm possessiom have e3il r been reread or may be destmyed,and agree to Pmtecl,defend and
save harm ne View iatOrttrrrl km any and all dabns and dew for bss of which may be made against them
by of or curt h theaemalkm of saw reinsh m Mwed,, suds tda-s or demands are or are not wltoily
false or
(Address)
AY
(Sigar a and Address of Relative or Legal Repressuative)
5ipneoontntsdate. November 9 2008
Disposition of Cremated Kemains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
mail to
other arrangements_Please specify: F H w i p p pick up
If pL&ermation of aemated remaim is requested,check#sere x
Revision:49yBt74
/911M, 07