Dardis, Albert TO T�� O
QU EE
PWE VI `���
EW CEMET
ERY AND CREMATORIUM1
C�hK-ER ROAD, QgNSB�l,
THEW YORK 12844
(518) 745-4476
(518) 745'•4.477
,Fame Funeral Director
_ Case#.
Of Cremati
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Time vC
Cremation Started
7Ime `�' � �
Cremation Completed
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Type of Container
Remarks Z
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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 wdersigped requests and authorizes Phna View Cmmetorkxn,in accordance with and subject to its Rules and Regulations to
cremate the remains of
Igo e�r
(Name) (Sex)
_ '36 Tialn e� SI
( ) (City) (State) (Zip Cam)
who died on j day of !! Di t— 20P-f
(place) ( )
Name and address of nearest tivinp relative or name of person atamrinng cremation:
( ) r (Address) r
Relationship to the deceased
Name of Funeral Home lquN�� QA1Z�C ruNf4At 6M1
IMPORTANT:
1 represent that to the best of my ierowledge,the deceased(ties) (has no alw defibrillator,battery,battery pack,Power
cell,radioactive implant or radioactive device in his or her body.
I certify that I have full power and authorization to arrange for the aamation of the remains and to direct the disposition of the
cremated remairns,that any perm-W possessions have either been removed or may be destroyed,and agree to protect,defend and
save harmless Pure View Crematorium from any and ad"aims and demands for toss or"scrapes which may be made against them
by reason of or connected with the cremation of said remains;;as diracyed,whether such"eimns or demands are or are not wholly
groundless,false or fraudulent.
(Witness) (Addreae>
and AwddrqCs of Relative or legal Representative)
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pine View Carsmatorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:
if pulverbation of cremated remains is requested,check here
Revision:April 18.2007