Denno, Harold Z"O74N OF QUEEVBU9KY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
II f II Funeral Director
Name �29 ,Ao Case #
Date of Cremation Ldd ( , zooy
Time Cremation Started �� h
Time Cremation Completed r°^�S n
Type of Container rc C ty���P ST C �r
Remarks :
Z° `1:00&7
10 F9
i
i
i
i
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbtuy, New York, 12804
Cemetery Office:(518)745-4476,Crematorium: (518)745-4477
Audxxt edon to Cremate
The undersigned requests and authorizes Pine View Crematorium,In accordance with and subjecx to its Rules and Regulations to
crWriale the remains of:
oG 0-
(Name) (sex)
(sue) (city) (sue) (zip Code)
who died on ZO day off 2t
at b o .n. Q,n TTA�IJ
(Place) O
Name and address of nearest wing relative or name of person mawrizing crernetion:
(Nam) t )
Rela tionsttip to the deceased n
Name of Funeral Hama !1 C��"71�.JLi2� C�V OU2—
IMPORTANT:
1 represent that to the best of my knowledge,the deceased(has)or dd brklator,battery,battery peck,power
cell,radioactive Implant or radioactive device in his or her body.(Crdie )
I cm*tint I have full power and au wlization to arrange for the aemretion of the remains and to direct the dsposkion of the
cremated remains.that any personal possesa11 1 have eititer been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View Crematorium from ary and all cleats and demands for loss or damrage 4 wtristt may be made against them
by reason of or oorrred.�ted with the cremation of said remarts as directed,whether such darns or demands are or are not wholly
ororstdlsawfale,r., prtirftuddr
(Witness) O
(Sig eLm and Address of Relative or Legal Representative)
Signed on dit date:
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispaae of the cremated remains as follows:
Mail to
Other arrwVwn Ida-Please spw*.
If pulverization of cremated remains is requested.check here X
Revision:April 18,2DO7