Holmes, Susan i
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PINE VII CEMETERY AND CREMATORIUM
WAXER JAD, QUEENSBURY, NEW YORK 12804
8) 745-4476 (518) 745-4477
Funeral Director_ )III, K MI=i1
Name 5 Case #
2�
Date of Cremation_
Time Cremation Star -2C)-4tj
Time Cremation Comp red IU " 53 l�M
Type of Container_ _ �,C o�►� C W_U�fl S� �,� `
Remarks : S
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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 undersigned requests and authorizes pine View Crematorium,in
cremate the remains of accordance with and subject to its Rules and Regulations to
(Marne} I -
. (sex}
— T� �(�) 1- c.� �E�,J max.-.cat, .
who died on a rl� (state) Rip Code)
day of-4� 20 0 g
at -'�, e,___ '
(off)
(Address) --}-`—�
Name and of nearest living relative or name of Person a"
(Name) I �10�'"9 cremation:
(Address)
Relationship to the deceased
Name of Fur aiHome M. B. Kilmer Funeral Home
IMPORTANT:
I represent that to the best of my knowledge,the deceased
call,radioactive implant or radioactive device in his or her body.s(C no) maker detWilator,battery,Untery,pack,power
1 certify that I have full power and authorization to arrange for the cremation of the remains and to direct the cis
cremated remains,that any personal possessions have sillier been removed or maybe position of the
save harmless Pine View Crematorium from any and all Claims and demands for to or destroyed,and agree to protect,defend and
by reason of or connected with the cremation of said remains as directed,wtcethar snxtt daa demandsare madeare agalinst them groundless,false or fraudulent.
(witness) (Address)
(Signature and Address of Re la or Legal Representative)
signed on this date. " Z �?._ d S
Disposition of Cremated Remains
I hereby drect Pine View Crematorium to dispose of the cremated remains as follows:
Veil b
Ofner arrangements-Please Spa*:
if pumir¢ation of cremated remains is requested,check here
p rW=January 1,2009
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