McNamara, Ruth i
TOWN OF QUEEM5B�u�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director PPa�%' an
Name Ru4 wx Lit g Case #
Date of Cremation Av1%b0 L. ZW5
Time Cremation Started ljgo Ah
Time Cremation Completed 9: TA
Type of Container F.cl�jcArulwvr CK a tTRSt CFlS�-
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:
n ,;
(sex)
(Name) ,
5 ra
(Street)
(CtiY) (state) (zip Code)
�
who died on
21 day of 20_
at Gle '2/ rJ
(Place) (A dress)
Name and address of nearest living relative or name of person authorizing cremation:
(Name) (Address)
Relationship to the deceased (J
Name of Funeral Home ( `
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IMPORTANT: maker,defibrillator,battery,battery pack,power
I represent that to the best of my knowledge,the deceased(has)o (has no)
cell,radioactive Implant or radioactive device in his or her body.(C
I certify that I have full power and authorization to arrange for the cremation o the remains be destroyed and agre t disposition pro the
tect,defend defend and
cremated remains,that any personal possessions have either been removedY g against them
save harmless Pine View Crematorium from an and all claims and demands for loss or damages which may be made aga
by reason conned with the cremation of said remains as directed,whether such claims or demands are or are not wholly
`grroundl Ise or ant•
x (Address)
Add
( ) i
(Signature an Address of Relative or Legal Representative)
Signed on this date:
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Disposition of Cremated Remains
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I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
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Revision:January 1,2009