Haines, Marjorie �o OF QUEEN,5BU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
MArII&I'L't
Funeral Director K110)Name iluj Case # ZC6
Date of Cremation E Z11 -7g)5
Time Cremation Started
Time Cremation Completed
Type of Container
Remarks :
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12804
Cemetery Office:(518) 7454476, 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:
(Name) (Sex)
581 TPr`/LaE� � � 2hnlJ��+.� N4 1283Z
(Street) (City) (State) (Zip Code)
who died on day of 20
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at �t L�, �Gk I `r6'� - 1,c1�15 ��L�S� t v /Z $o
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
X � r,,.i Mika (e 13 TkY��
(Name) (Address)
X Relationship to the deceased Armen l l'reElrL
Name of Funeral Home
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or pacemaker,defibrillator.battery,battery pack,power
cell,radioactive implant or radioactive device in his or herbody.(Circle ne)
I certify that I have full power and authorization to arrange for the cremation of the remains and to dined the disposition of the
cremated remains,that any personal possessions have either been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View Crematorium from any and all claims and demands for loss or damages which may be made against them
by reason of or connected with the cremation of said remains as directed,whether such claims or demands are or are not wholly
Mg�roty ,fakes or fraudulent.
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7 / ( )
(Signature and Add of Relative or Legal Represen ive) '
Signed on this date: (O 2$ 6
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