Burrell, Margaret To 0
P TN E Y(E'GY C E tY(�TE�R ',
Y QUEE9\�523UTr
ROAD, CREMATORIUM
QUEL°NSBVRY, N-EW YORK 12804(518) 745.4476 (518) 745*-44477
Funeral Director
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^ate Of Cremat ,.On _ Casey SZ
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Cremation Started
Tlrne Cremation
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Town of Queensbury
Pine Phew Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery OKim:(518)745.4476,Crematorium: (518)745-4477
Authorization to Cremate
The urdersigrred raquasts and autinorizas Pine View Cmmaooridm,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
CC
NWPO (SOX)
2G CyNNFtdt_D ill i k20 t
(Street) (may) (State) (Zip Code)
who died on day of tr.j^vt( -- 20
- r
at
(Place) (Add
Name and
address of nearest"V relative or name or person sutinorb*v cremation:
(Name) (Address)
Reistionstap to the deceased
Name of Funeral Home
IMPORTANT
I represent that to the best of rrry Ivrowledge,the deceased(has)or(has no)peoemakw.detlbrillator,battery.battery ram,power
call,radioactive Implant or radioactive device it his or her body.(Circle One)
I certify diet I have full power and authortzetion to wrongs for the cremation of the remains and to direct the disposition of the
cremated remains.that any pank net possessimm hero either been removed or may be destroyed,and spree to protect,defend and
save harmless Pate View C rematorkm from any and al claims and demands for loss or dernages which may be made against Mom
by meson of or connected with the cremation of sold remains as directed.whether such claims or demands are or are not wholly
groundless,F or fraudulent.
3so3 Syrac„:� ,fvY f31t5 -`t7`!3
(Address)
D So&gw PY 131is`q�'�3
(Signattxe and Addtew of Relative or Legal Reprasentmive)
Signed on this date: J'4WV Oily -21 0d _--
Disposition of Cremated Remalrs
€hereby direct Pine View Cremaoortum to dispose of the cremated remains as Wows:
Mai!to
Other arrangements-Please specify: ' �f h t- i T -,I i! I ; i ,c
it pulverization of cremated remains Is requested,check here
Revision:Aprl 19,2W7