Pinsonnault, Marion �O q+N OF QUEENs5BU9�y PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name 6410- �O50nnqvit Case # 303
Date of Cremation ((3
Time Cremation Started A
Time Cremation Completed (Ui2GAh
Type of Container j
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Remarks :
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# 3�3
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:
(�ar ri L I+ F
Clot);A * �) Adoe A G/tns 4a//S NY ) 2 YOf
(Street) City) If (State) (aP Code)
who died on day of � 20001—
at 61eix Falls f-f� Pik-1 /oofa� LS1,,(ilenr Falfs..J Vz8b1
(plow) (Address)
and address living relative or name of person auero lift cremation: f
(Name) (Address) 6—b i.s dy'V3
Relationship to the deceased r---a t e.-'10
Name of Funeral Home 1) • &ICe,('
IMPORTANT:
I represent that to the best of my knowledge,the deoeea or maker,daWflator,battery.battery Pads,power
cell,radioactive hnplarft or radioactive device in his ar ht 1 certify that I have full power and m*wrizatkm to arrange for the cremation of the remains and to direct 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 hntrrrless Pine View CrOM810rium from any and 911 claims and demands for bes or damages which may be made against them
by or connected the cremation of sold remains as directed,whether such claims or demands are or are rat wholly
9
/ La S1 Q
(witness)
Address
(Signature and of or Legal Representative)
Signed on Oils date: 7_)q I 0
Disposition of Cremated Remains
I hereby direct Pine View Cremratorkrm to dispose of the cremated remains as follow.
Mail to
Other arrangements-Please spedfy:
If pulverization of cremated remains is requested.check here
Revision:January 1,2DW