Fowler, Marianna (O q+N OF QUEENSBWKY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name �kr'kCIAn6% Fvw (tT Case # 3r�
Date of Cremation To 1y 7cog
Time Cremation Started
Time Cremation Completed Iu, 0 �(Z
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)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.-
(Name) (SOX)_
(Street) h` (My) (State) CDP Code)
who died on day of 20 D g
at Tcst.t l �c�,ca�•-`
(Place) ( )
Name and address of nearest living relative or name of person authorizing cremation:
(Name) ( )
Relationship to the deceased (�;k— --
NameofFunwelliome M. B. Kilmer Funeral Home
IMPORTANT:
I represent Chart to the best of my I urMedge,the deceased(has) cemeker,detlorilletor,battery.battery Peck power
cell,radioactive implant or radioactive device In his or her body.( ne)
i certify that 1 have full power and authorization to arrange for the cremation of tine remains and to direct the dispositbn of the
cremated remains,Chart any personal possessions have edher been removed or may be destroyed,and agree to protect,defend and
save harmless Pane View Crematorium from any and all claims and demands for loss or damages which may be made against them
by reason of or c ommK fed with the mer natia of said remains as directed,whether such Bairns or demands are or are not wholly
groundless,false or fraudulent.
oftoss) o (Address)
(Signature and Address of Relative or Legal Reese)
Signed on this date: k'-^-�"`-► ` o
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 1,2M