Higgins, Antoinette To OF
QU EE
WE VIEW CEMETERY AND1 �J
�ii�%�K.ER CREMATORIUM
R0�1D
' QLtENSBURY, NEW YORK 12804
(518) 745.4.476 (518) 745.4477
Funeral Director
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Name lrta�n��
Cased.
Dace Of Cremation
Time Cremation Started
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T 1 m e Cremation Completed
Type of Container 1/7
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Remarks
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Town of QueenslwN
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 wWer4V wd requests and aul Pkw View Cramatorkrm.in accordance with erd subject to its Rules and RegulatIl"I to
cremate tttQ remains of n r—
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(Name) ,/i ( )
s � /� .iCl i z�=o�
Y i ws (City) i (StasI�
( ) te) (zip Cs�re)
Of 20_0—
who died on
at (Place) (Address)
Name address of nearest mu,itive or name of person
(tee) (Address)
Relationship to the deceased
Name of Funeral Home '
IMPORTANT: the deceased(tree) (tree no) Aker,defiOr�tor battery.battery GO•Puy
I represent that m the beat of ttty 18098e h life ca her body
cell,radioactive implant or ra&mcfi�a
I cw*that 1 have UA power and agMarizaa►ID arrange tar the tref" tlon of on repolm and to dint tfre dsposftn of the
haveelh destroyed.arid been removed or may be des and agree to protect,defend and
savecrematedhamless Pine View w ftm any and all clal and dermtds for toss or damages vdd h awy be nrede aWkIst them
by or wdth the a+emation er said es vr�suds ar darrrartds ane or are rtot wrhoUy
, )
and Relative legal Rife)
Signed on this date: 1 Z // � v
pin of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as MOWS.
Mail to
Other arrangerneMs-Please specify:
If pulverization of cremated remains is requested,check here
Revision:April 18,2007