VanTassell, Raymond Sr. O .
F QUEE9�SBU��
PLNE YIE`PY CEMIMRY AND CREMATORIUM
�hKER ROAD, QUEp.NS6URY
NEW YORK 12804
(518) 745.4476 (518) 745-4.477
Funeral Director
Name �
Oate Of Cremati Casedon
Time
Cremation Started
Time Cremation Complet d
Type of Container qrt
CzH
Remarks
J S 3
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 and subject to its Rules and Regulations to
cremate the remains of:
Raymond L VanTassell Sr Male
(Name) (Sex)
130 fort Edward Road Fort Edward Nv 1 R
(mot) (City) ' (State) (Zip Code)
who died a, 22nd dayof December 20--U
at his homy
(per) (Address)
Name and address of nearest living relative or name of person au#xxt irrq cremation:
(Name) (Address)
Relationship to the deceased
NameofFuneralHome M.13.KIlmer Funeral Home
IMPORTANT:I represent that to the best of my knowledge,the deceased(has) (has no) er,defibrillator or any other battery operated
device In his or her body. (Circle One)
I certify that I have full power and authorization to have either removed or may be nge for the cremation of the remains
estroyed,and agree and to direct the rotprotect dahxW and
on of the
cremated remains,that any.Persona possessions
save harmless Pine View Crematorium from any and all claims and demands for loss or 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 rot wholly
groundless,false or fraudulent.
(Witness) (Address)
(Signature and Address of Relative or Legal Representative)
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
Revision:January 1,2006