Ledford, Janet 1,fir.. :• -..... ..... .,
�oOF
PWE VTE 0 U-�EE9�SB
20,
W CEMFTE•RY AND ROAD, CREMATORIUM
(518) 74�44 6 SBURY' iYEW YORK 12804
(518) 745•.4.477
Funeral Director
\'ame
Date Of Cremation Case � .
Time Cremation
Started
Time Cremation /
Completed
Type of Container
Remarks' J�
M =
x.
Vi-
�IOU
Town of Queensbuty
Pine View Cemetery and Crematorium
71 Quaker Road,Queensbury,New York, 12804
Cemetery Office'(518)7454476,Crenutodum:(518)745-4477
Authorization to Cremate
The undersigned requests and m*wdlzes Pine View Ccen1810riwn,in accordance vIlh and stbbjed to its Rules and PaJulatlorrs to
cremate the remains of: A/ _
(Name) (Sex)
eye_,_ (zip code)
(Street) ( >
who died on O o�k day of C>Z/� 20���/Z
�-f L Ll�1' /
(Place) (Address)
Name and address opuTrest Huang relative or name of person arnl wdzing exenumon:
(None) Oddress
)
Relationshlp to the deceasedName of of Funeral Home
IMPORTANT: aeaed(has �no emaker,delibrillOW b o ary,battery GeCK,PMW
f represent that!D fire best of my broaded�,the dec
cell,radioactive implant or radioactive device in his or her body-( e
I certify that i have*A power and adhorizalion to an'gW for the CMMWW of fire r+mrim and to direct the disposition of the
cremated remem that any personnel Pow have either been rerwnd or may be destroyed.anti agree to protect,defend and
save harmless Plne View Crwratodum from a"and alledaitrs and dMWKb for ices ordwsaWs vddc h m"be made against them
by reason of or connected vdih the aeawdon of said remains as daecfe I vdmew such edeins or de ";are or are riot wholly
ground".false or fiaudtdanL
t.
(vlrctrress) (Add)
(Signature and of .or Rye)
$lenCd M this date:
Disposition of Cranate d Remains
I hereby direct Pine View Crematorium to dispose of the OwneWd remains as follows'
Mail to
Other arrangements-Please sPedgr.
If pulverization of aemated remains is requested,check Rare
Revision:April 18,2W7