Lockhart, William �O O ,
PWE YfE CREMATORIUM
QUEE9\�5oUTry
�' CEMETERY AND CREMA
�R ROAD, NSg�.l,
Q(lEE
(S 18) 745.4g76W YORK 12804
(518) 745.4.477
Funeral Director
Name �jtiIl(k.ti LoC���q� Sf fFo
Oa c e 0f Casein. ((3
Cremation
Time C ah Z� 00
Cremation Started
;UC,
Time Cremation Completed
Tyke of Container NooG�
�emar 'Ks SEA Na � S
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:
) I LL LAIM oC-t<�AV,
(Name) (Sex)
i-nt3CyiF. ,p S2ie\ - AQi a�, DU FM .5 Rtj
(Street) (City) (State) (Zip Code) � (�
who died on i day of U CA 20L
E
(Place) (Address)
r��reeme and address of aearest ilving relative a Harris oiperson a�hortr3ng :— - R L m o tom' M
C'15AR6A � , `SHoM�or`i) 3176c, �tPPE1.5155E� RD.� , A oIs-4G
(Name) (Address)
Relationship to the deceased
Name of Funeral Home
IMPORTANT:
I represent that to the hest of my knowledge,the decei (has) (has no)pacemaker,defibrillator.battery,battery pack,power
cell,radioactive implant or radioactive device in his or her . Circle One)
I certify that I have full 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
by reason of or connected with the cremation of said remains as directed,whether such claims or demarxis are or are not wholly
9 ,false or fraudulent.
41
�Alltrttiste�r _ (Address)
r �4�� , , l :suemPeF�lSS�7r �Cp o ��I% O a s 7
(Signature and Address of Relative or Legal Representative) J
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 specify:
If pulverization of cremated remains is requested,check here
Revision:January 1,2009