Harvey, Shirley rrnq+N OF QUEEN
,5BU-9�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director BA11?
Name r'Q Case # 31�(
Date of Cremation � ��y ZD zM
Time Cremation Started I;Uy
Time Cremation Completed 314 Ptl
Type of Container ly'rol�C° CUwFQ20 Sr(p,UP CA-s
Remarks ;
Z:►OP►�
2ss��
.4 314
Town of Chieensbury
Pine View Cemetery and Crematorium
21 Quaker Road,4ueensbury. New York, 12804
Cemetery Office:(518)745-4476,Crematorium: (518)745.4477
Authorization to Cremate
The undersfgrned requests and augwftes Pine View Crematorkmn,in accordance wilh and str W to its Rules and Regulations to
c remate the remains of:
y� � � �d� �� � ��eo
(street} (GII10 ( }
who died on day of. ��L 20.0
Cv
at
(Plow) (Address)
Name and of nearest ovkng relative or name of person sumortzkv cremation:
(Name) (Address)
ReWflorship to the deceased,( �
Name of Funeral Home
IMPORTANT: no crier,dr�tator,t�a►1ery,battery Pack.Power
I represent that to the best of my knowledge,the deceased(has) (Fme
cell,radioactive implant or radloadive device In his or her body.(
I oe*that 1 have tut power and S oft tlon 10 arranpe for the aemedw of the remains and 10 drred the disposition of the
cremeW remains."any Persorrei possessions have either bean rerrroRM ar may be destroyed.and agree to protect.defend and
save f rarrrdess Pine Vk!iw
by reason sdid reweira saw�pd, such dams or demar>I are or are rot w1wilyy
of
31
OL
( and Address of epel Reprew alive)
signed on this data_ 7 C 6 9
Dispositions of Crerneted Remekrs
I hereby died Pine View Crematorium to dispose of the cremated remains as fotlaws:
Mail to
Other arrangements-Please seedy:
if pulvefind n of cremated remains is requested,deck here
Revision:April 18,2007