Baldwin, Kenneth rlll q+N OF QUEEN,5BUri
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director M6 �1Ci1
Name— King� lk�G+w�` Case # 3�(�
Date of Cremation
Time Cremation Started__ �711tc Ah
Time Cremation Completed �': sfS
Type of Container �rct oar PO v tr C' ' J
Remarks :
M A Tti TS S I)M 4 � 11 S AV)
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 undersi W mquesls and authorizes Pine ViewCramaWrium,in acoor tin rxe with and subject to its Rules and ReWiations to
(Name) (Sao
MOM) (CAY) (Sires) (Zip Code)
who died on _ day of Zp n q
�-t
(Place) (address)
Name aril address of nearest living rek*n or name of person auftrizktg cxerraft:
(Nerve) (Address)
Relationship to the deceased
Name of Funeral Home M. B. Kilmer Funeral Home
IMPORTANT-
I represent that to the best of my knowledge,the deceased(hes) no`pecarneber.defibrillew.battery beae►Y peck power
call,radlowd"implant or redioacWe device In his or her body.
1 ow*that 1 have frM power and 8uftrlwdw to aeange for the cremation of the rerrreks and to dkact the disposition of the
cremated remake,that any personal possessions have either been removed or may be destroyed,and agree to protect,defend and
save handers Pine VIew Cxemaoorium from any and al dakrs wW denmrrds for loss or damages which maybe meft agairo omm
by reason of a ccxKrecded wkh tine cremation of said renvftw as directed,whet w such claims or dement are or arena wholly
groundless,false or*auduMnL
O (Address)
(Signature and Address of Relative or Legal Represernative)
Signed on this date:
Disposition of Gemated Remains
i hereby direa Pkte View Crerrrelorium to dispose of fhe cremated remake as follows
Mail to
Other errenrgsmerns-Please specify:
If pulverbwb of c rerna W remake is requested,check here
Revision:January 1,2009