Roberts, John ' rO Y N OF QUEEVBUr�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director—
Name A,� �V6(-A -s Case # 365—
Date of Cremation T Ul4 (3 � h
Time Cremation Started I'UU�I(�
Time Cremation Completed 3� OS Ph
Type of Container �, �„�� 1�J'ORO �CG'P0 as�
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
cremate
reque is and authorizes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
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it 11'.iri:i
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(Street) ( ) (State) ip Code)
who died on __ ZOOM OM� day of 20
at —
(Waryal �
Name an address of nearest living rreiative or name of person awxwtzirV cremation:
(Name) (Address)
Relationship to the deceased4-A
Name of Funeral Hoe (� t. .
m
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)OrAi
pacemaker,defibrillator,Batt cell,radioactive Implant or radioactive device In his or her body.(Circle ) 8ry,battery fa.Power
I certify that I have full power and authorization to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,that any personal possessions have efther 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 ai
by reason of or connected with the cremation of said remains as directed,whether such claims or demands are or are not wholly tham
groundless,false or fraudulent.
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7nature'and
Address elative or Legal Representative/ C
Signed on this date: `.L Kai
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:April 18,2007