Martin, Edward r-To OF. QEM5UEB URY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 51 N ft7RO
Name Wa� N(cr��� Case # 3�1,
Date of Cremation AU5, I Zr-I ZUUS
Time Cremation Started S h
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Time Cremation Completed I I- �G
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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 %
The undersigned requests and authorizes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
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(Name) (sex)
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(Street) (CRY) (state) (Zip CMWI
who died on day of u G u ST 2001 L
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(Place) (
Name and address of nearest 16ring relative or name of-0afto 19, orizfng ad is— -— — — — —
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(Name) (Addy / st
Relationship to the deceased ('D i IPEU
Name of Funeral Home
I represent that to the best of my knowledge,the deceased(has)or no)' maker,defibrillator,battery,battery peck,power
cell,radioactive implant or radioactive device in his or her body.(Cir +na)'
I 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 either 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 against them
by reason of or connected with the cremation of said remains as directed,whether such claims or demands are or are not wholly
7undless,false or frauduWd.
k � ar (A C7ktktress)
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(Signature and Address of Relative or L6gal Representative)
Signed on this date:
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Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:
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If pulverization of cremated remains Is requested,check here
Revision:January 1,2009