Galusha, Earl �O O
T� F QUEE9,�50UrpPINVTEW AND CREMATORIUM \J
CEMFTEEY
gVXKER ROAD, QUEENSBURY NEW YORK 12804
(5 18) 745.4476 (5 18) 745'-4477
_ Funeral Director
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Oate Of Cremation
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Time Cremation Started
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Time Cremation Completed f
Type of Container ti I
Remar'Ks 09 AS1
44 —__—
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 undersigIned requests and aLdwrtm Fine View Crematorium,in accordance wkh and subject to Its Rules and Reputations to
cremate the remains of:
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(Name) (sex)
3'f b l �-A-1 cv R y !7o R d ��i�f s f a ni S°pA, AN1�1 a
( ) (City) (State) (Zip Code)
who died on i X (h day of J�4N�+ 1 20—C2
:0 9A!A P0
(Place) (Address)
Name and address ofnWestliving relative or name of person authort mV aarrtation:
Tht'ddeh� ustiaeis� 1�1� lY
(Name) (Address)
ReWbonsNp to the deceased
Name of Funeral Home
IMPORTANT: gm no)I represent that to the best W01M in his or her ( )c+rde ) . P
00 de
ceU,tadioedive ntVWt
or radimcitiva I cw*that I have*A power and autlwriradon 10 arrange for the cramoon of the remains and to direct the disposition of the
creme:ed remam that any perjonai poggassions t>ette either been renwved or may be destroyed,and agree to protect,defend and
so"harmless Pkw View Creffgoxium*am any and aN clai and demands for loss or damages which may be amide againd Own
by reason of connected w1h dw aamabon d add remainsasdirected.whether such chime arar dsmartds are or are rat whokyy
groundless,false or fraudulent.
R�N fF�'t� ►� 3Ak Y (�ue.eAlAC1111,
rmess) (Address)
(Signature and Address of Relative or legal Repro ive)
1
Signed on this date: ✓
Disposition of Cremated Remains
I hereby dined Pine View trematodurn to dispose of the cremated retrains as fokows:
Mail to
other artargemertls-Please speciy:
if puivertzation of cremated remains is requested,clack here
Revision:April 18,2007