Cleveland, Anne fir.. ...... .. ..
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OF UE `,c
VIE E k1c.ER W CEM4TERY AND CREMA n '-\J
ROAD, QUEENSSURy TORIUM
(518) 745.4-476 NEW YORK 12804
(518) 745.4477
Name Funeral Director
Cast d PVC i
Dace Of Cremation Case#,
Z ,/6 vg
Time Cremation Started
Time I(�G
e Cremation Completed
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Type of Container
.. .Remarks 0W 7 N
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Towne of Queensbury
Pine View CemetM and Crematorium
21 Quaker Road,Queensbury,New York, 12804
Cemetery Office:(518)745-4475,Crernatonum:(518)745-4477
Auttwrization to Cremate
The undersigned reeds and auU►ortzes Pine View( tong".in accondar"with and s A*d to its Rules and RqpAabom to
cremate remains of:
A)
(Street) (State) (Zip Code)
� ( 'Y) \/�
who died on day of ✓ L�`7 2D—Qj�1p�
UJ�
(Place)
(Address)
Name and address of newest 7reWm_f of P� +9 aerrnadow
(Relationshipto the deceased 1 I
Name of Funeral Nome _ (�
iMPOFrr Nr deftMaW or mry other be ery opt
i represent that to the beat of my k owledge.the deceased(has)or pm as)per '•
device in his or her body. (Ck a one)
1 certify Chet t trove id power end arrdwri MUM b erraaga for am aerrmlion of the remains and to deect the dsp)s%m of the
cremated rwrAkW VW arty poemai p here do P been 6 wwAd er wAV be daslroyad.and agree 10 protect.defend and
sere inarrrnless Pfne View QramaMrium from any and d creme and dernnar I fences or demeyas Wild grey be onade agaf 1 thorn
by reasa n dcoranedad VM site oanrdOn d asid regains as dreded.wira�rerandr deierw or daraarnds are or are not Mtoq
s
( and Ads d )
Signed on this date:
Z ILI7/) '
Dispositionof Cremated Remains
t hereby►direct Pine View CrematoUnr to dish at the cremated remains as fA wx
Mad to
Other arren9nrne"-Please speW
if pulverization of cremated remains is rsgussted cl"N c here
Revision:January 1.2006