Osborne, Judy �O
off, Q� ` -c � r
PLNE VIE r�'L4� LL
� CEMaTE•R`Y ^ 1�
t t�SIKER ROAD AND CREMATORYUM
(518) 74S4476S$UTtY, NEW YORK 12804
(518) 745:4477
i dame Funeral Director
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Oace ' Of Cremation Case#•
Time Cremation
Started �
Time Cremation /
Completed to qO
Type of Container
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 atMorixes Pine View CrOmatorlum,in accordance with and sub)ect to its Rules and Regulations to
cremate the remains of:
N. r� vr/Y
(Name) jjj�111
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( ) (city)
I (State) (zip^o )
who died /O P-- day ofat
O (Address)
Nam7(Nam)
address c' living relative or name of person 0n JL�'//
b
Relatiip to the deceased 3Nameuneral Home v (Z
IMPORTANT: np aker,de�ibriBator,battery,battery peck,Pmer
I represent thst to the best of or f,e in his or her body.
de°ed ( (has )
call,radioec"knplent
I have AA pager and augKwIzedon to arrange for the cremation of the remains and to direct the disposition of the
i oeNfy thatthat arty persataa possessions have either been reproved or may be destroyed,and agree to Protect,defend
aemeoded r have
save harmless Pine View Qpemalorium from any and all chins and demands for loss or damages which may be made against
by with aemalion of sold remaa'ins as directed.whether such deems or demands are or are not whoNy
grO1nd � 1 /j
(Witness)
• UU fig
( Address of R )
Signed on this data. Z U 6
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains eS fellows:.
Mail to
Other aRangements-Please sPecfy:
If pultr mt*n of cremated remains is requested,cha&here
Revision:April 18,2007