Baertschi, Edward OF
P Ul E YY QUEE9\�5OUT
F-VV CE"TERY AND CREMA
gL4'XkZA ROAD, QVEZ'.'.NSBUp TORTUM
(518) 745.4476 �w YORK 12804
(518) 745'.4.477
Funeral Direr- tor��
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Name
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Gate Of Cremation Jan
7
I 'me Cremation Z�09
Started
T 1 me iU
Cremation Completed 73
Ty ?e of Container ce _
Remarks 0
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Towti of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office:(518)745-4476,Crematorium: (618)745-4477
Authorization to Cremate
The undersigned requests end atowtxes Pine View Coema orArm,in accordance with and subject to Its Rules and Regulations to
cremate the remains Of: /11
L c�GJ�S � 2.YL I SCE) / n c-
71
( ) (city) (State) (MP Code)
who died on 2 Z day of.�/ 6�j 20-rL)L
at
(place) ( )
Name and address or nearest living relative or name of person&Awxtft cremation:
1- ;rl�
O
Reiatiorrship to the deceased t �G
Name of Funeral Home T / /� I J �L
IMPORTANT: ) oaker.def�r�or,battery,battery Peck,
I represent that to the hest of my lcnowiedge,dw deceased(has)
PMW
ceu,radioacdve implant or radioactive device in his or her body.
I OWW#It I have full power and wAhorkow a arrange for the cremation of the remains and to direct the disposition of the
cremated remains, anal possessions have etmer been removed or may be destroyed,and agree to pmlecL defend and
save tin from any and all d whatw�da da dsdwmgeswhlch saareeor erne
by
(„viv,ess) ( )
NLIE
(fie and Relative or Legal ePresentalive
Signed on this date: 16
Dis wAkin of Cremated Remains
I hereby direct Pine View Cren mxium to dispose of the aemated remains as follows:
Mail to
Outer anangemeras'Please specify
If puhvri obw of cremated remains Is requested,check here
Revision:April 18,2007