Lackey, Robert T074N OF. QUEEVBU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director [31�Kj 2
Name l`°���{ l�c�y Case #
Date of Cremation A,, 5 2$ 7669
Time Cremation Started 0 AO
Time Cremation Completed 1-s- A�
Type of Container Ca.car�r Lr� O,� Firm- IIqAe
Remarks :
i0. 1st
a,
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office:(518)745-4476,Crematorium: (518)745-4477
Auftriza*m to Cremate
The undersigned requests and suvwftes Pine View Crematorium.in s000rdwm with and subjea to its Rules and Reguietlom to
IF
cremate d //
jNam)
( ) (car)
who died on of, 925
200
tJ teD3
( � (Address)
Name rom of nearest wing am or name of Person auftorb*v asmaWm
( z/
Re>a MOW to the deceased T�
Name of Furwal Home
IMPORTANT: the deceased(hes)or(has no)pacemaker'.doWillator,battery,battery Pedc.p�
I represent that to the best of my imowiedge,
ca radioactive"Owd or radioedlve device In his or her body.(Cirde One)
1 certihl that 1 have U power and soo nation to arrange for the awns*M Of the rerrrains and to dses the disposition of the
cremated remain%that any persond pos essioM here elthat been rawn"M or mey be desboyed.and agree to Prates.defend and
save Pine View Crertratorir m from any and aM cieirtrs and demands tar toss ar damages which mall be made against them
by or with aarrrstiotr d said ranraire as wttetlter such claims ar demands meet are riot whoNy
or
M, ) (Addr+ess C�
(SWmwreandXiiMdrReWlveorLegW RePresen>ative)
this date l v
Dispos8ion of Cremated Remains
I hereby direct Pine View Cmff* dum to dispose of the aemated remains as follows:
Mail to
Other affengements-Please spedy
If psvenzMw of cremated remains is requested,check here
Revision:April 18,2007