Sawyer, Donald Sr. �o�� OF QUEE9\�5OU-(�y
PINE VIEW CEMFTERY AND CREMATORIUM
Cat kkER RO11D, QV.P.ENSBURY, NEW PORK 12804
(518) 745.4.476 (518) 745-4 .77
Funeral Director
I\ame � �.
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Date Of Cremation
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Time Cremation Started 1:0
Time Cremation Completed .� .0�
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Type of Container
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Town of Queensbuly
Pine View CemeINY and CMTUItDdUM
21 Quaker Road,Queer'I New York, 12804
Cemetery Office:(518)745-4476,Crematorium: (518)745-4477
Authorization to Cremate
The undersigned requests and autitoft8s pine View Cregatorium,in a000I with artd sdgWto its Rules and fons to
cremate remains at. V�
(Name � -u.( /Z-eCT/
-yCZS
1, i d`J'J (state) CziP )
(Street) (City)
Of
who diday" 33
J S b�P ►.3.3
at (Address)
(Place) I
Name and address of nearest I" miative or name of Person authorizing cremation:
( ) (Address)
Relationship to the deceased
Name of Funeral Home
represent R Out to the best of my
the deceased(has)C � ��.banery.battery pack,power
cell,radioactive impw or radioactive device In his or her body-
the
i certify via f have fkA power and adtwt�too arrange for the cremation of 20 nos end to and disposiI of defend and
Imsrered'he
ellim been or�be demoyed.
mmated remdw.filet airy Paesonel and alit3aiAs and d for loss or damages void+mW be made S them
save harrriess V Qr ► of said remake es tiaherher such or demands are or are not wholly
by Mason Of Or
the
groundless, QI x YZ 2,f 0
dress (Address)
(fig and Address 017. or Legal Vie)
Signed on this date: I Z u
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Disposition of Cremated Remains
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I hereby direct Pine View Crematorium to dispose of the cremated remains as follows: I'
Mail to
Arran -Please specify:
Other gernents it
if pulver¢ation of cremated remains is mpmftd•dm&here
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Revision:April 18,2007