Rollman, Barbara Pw, .. EW CEM QU rZ LXSB
AND CREMATORIUM
ROAD, YORK 17804
QIIE�SBl1RY,
(518) 7gs.4g76 fix'
(518) 745'.4-477
F nerel Director � p
r
`d . e Of ematl.on Case
Te ' emation Started vo
- ^c : remaclon Com J�
pleted '2���•-
ContaineC „cc , � CQ�✓~
M z 0;n .
Town cf Quemoy
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office:(518)745-4476,Crematorium: (518)745-4477
Autltorization W Cremate
The underslcinw requests and aWhoriaes Pine View Cremakvkm,in accordance with and sutn)ect to its Rules and Regulations to
cremate the remains Of:
'hQ
(Name) (Sex)
(Street) (City) Ste) (Zip Code)
who died on �f ► day of_" f 20
J (Pwe) I (Address)
Name and address of neerest livkv relative or nerve of person au#wrfziv cremation:
r�
t-A,z,^
( )
Relationship to the deceased
Name Of Funerel dome P�A I':a.'-L - t
IMPORTANT: \
I represent that to the beat of my la w wredge,Vhe deceased(has)or(has rngypecemalt er.delbr�ator.battery.battery peck,power
cell,rsdioective implant or radioactive device in his or her body.(Cb�d )
I certify that I have U power and authorization to arrange for the cxemedon of the remaYts and to direct the disposition of the
cremated ran-Am,that any personal possessions have eitfter been removed or may be destroyed.and agree to protect,defend ano
save harmless Pine View G1rernaloritim horn any and al debts and demands for loss or damages which may be made against them
by reason of or connected with the cremation of said rernsins as directed,wlnetlhar such claims or demands are or are not wholly
Wot
C �// (Address)
-
v (Sigrou"and Address of Relative or Level ReoresentaL
Signed on this date: I ( G9
Disposition of Cremated Remains
I hereby direct Pine View Qrometorkm to dispose of the cremated remains as nvoor+�.
mom to
'er amenoements-Ptease specify-
if pulverization of Cremated remais Is reauesred,do*hl^"L_
Revision:April 18.2t r-