Whaley, Donald Sr. .L O OF
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CEMETERY AND CREM�'� ROAD, QVEENSBURY ATORiUM
(518) 745•4476 ' NEW YORK Izsoa
(518) 745.4.477
Funeral Director
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'ate Of Cremation Case#• 5 )0
Time Cremation Started
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Time Cremation
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Type of Container
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Remarks tr s
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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 authorizes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
(Name) ( )
(yam) (City) (S ) (Zip Code)
who died on .Z `2 Q day of 20— _
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(p1800) (Address) V G'f` y
Name and address of nearest living relative or name of person authorizing cremation:
G r NO /� 4A-, N-'Q L /: y 3�y s
(Name) (Address) _
Relalior>ship to the deceased
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Name of Funeral H yLome ,�7 / ! Z— 414 L"
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,defibrillator or any other batterry operated
device In his or her body. (Circle One)
I certify that I have U power and authorization to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,that any personal possessions have either been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View Crematorium from any and all claims and demands for loss or damages which may be made against them
or connected with the cremation of said remains as directed,whether such claim or demands are or are not wholly
,�gmundh5pk false
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(SignaturvAnd Address of Rely a or Legal Representative)
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please spa*:
If pulverization of cremated remains is requested,check here
Revision:January 1,2006