Caifa, JoAnn TOWN OF
QUEEN
5B
PINE VIEW CEMETERY ���.�✓AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
J S� t c� e4
Name � `
Case # 35
Date of Cremation
Time Cremation Started
Time Cremation Completed
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Type of Container 1prc owe r
Remarks ; Ii
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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 plus View Crematorium,
cremate the remains of: in accordance with and subject to its Rules and Regulations to
JD/4fci J CQ i
(Name) � f
11 y NAZk c V ; T (�S(e�x) y
(Street) �' ' `^a'=' N 7 v I G I
(Uny) (state) (ZIPCode)
who died on 1 rj day of A � n9
at E r - �47' ( t 70 5r �—I�5/
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
(Name) 1Z ��aK,)ot� N1 -t Vb
(Address)
Relationship to the deceased
Name of Funeral Home
IMPORTANT: " tit
I represent that to the best of my knowledge,the deceased(has)or� ►a no) maker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her body.(Circe
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 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
grou false or fraud nt.
(Address)
( ignature and rass of lative or Legal Representative)
"
Signed on this date: il to 2 ooT
Disposition of Cremated Remains
i hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mall to
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
Revision:January 1,2W9