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Tasker, Wilder
To OF P W E VIE Q�� L�T�� t_l. V' CEMETERY AND ��'�KPJt ROAD, CREMATORIUM QU8ENS9URY, NEW YORK 17804 (518) 745.4476 (518) 745.4477 Funeral Director Fame �� r � lFf SlAFF�i"� (7 C8Se# Gate Of Cremati.on 3 Time Cremation ~ ��) Started Time Cremation Completed f f I Z Q0 Txpe of Container rd�Lzu� Remarks Uo 10-36 431 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: 11 A . —FASkER MALE (Name) (SOX) � Bw RQ LAKE 66ORGE,`h 5 (Street) (City) (State (zip Code) who died on day of r 20_00 at&-.F.N_ i-AL" k--,Q C 4L, 1©D YARK MLE IS 5E6LL.S,-n ' I a 'O 1 (Place) (Address) Name and address of nearest living rel6tive or narhe of-person siltwrtzTng - C-RqL� -z� _:a:' 1 ASKEf2 , 1114: (ioR9► L&L�PzGC n 13,g�-IS (Na (Address)' Relationship to the deceased t 1) 1-FE- Name of Funeral Home !\ 7 R�2 IMPORTANT: I represent that to the best of my knowledge,the deceased(has) (has no) maker,defibrillator.battery,battery pack,power cell,radioactive implant or radioactive device in his or her body. 1 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 w with remains as directed,whether such claims or demands are or are not wholly groundless ud {v , a oC) LAKE C---Ea);-GC,1) I � gN� (W ) (Address) a KE G-6-o P,-C"E (SigFjunlao Address of Relative or Legal R resentative) Signed on this date: © � ' 1 9 ' 09 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 1,2009