Senneca, karen rrO q+N OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 6A �E4�-
Name ('rel" �ehtie« Case # 33L
Date of Cremation 5+ 3� 20Ul
Time Cremation Started Z:qIS 2h
Time Cremation Completed 3 P 1s P M
Type of Container Wuud 6,5�i ��� J� 5F_Cpti2 6--
Remarks ;
MA:Frj IZ r'I mot1j:- 9, . 30 P 1
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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
Autftorization to Cremate
The undersigned requests and authorizes Pine View Cremetorkxn,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
_ 41
(Flame) � (Sex)
O
ti�s7 AGUI /(l A
(Street) (City) _ (State) (23P
who died on day of `S U L 20(1 `)
at S—
O ( ) `
Name and ress of nearest living or name of person autho matron: �/
( ) t )
Relationship to the deceased
Name of Funeral Home
IMPORTANT: rheker. battery.battery p�k,power
I repasw that to the hest of my W*wiedge,the deceased(has) (hes )
cell,radioactive implant or radioactive device in his or her body.
I certify that i have full power and authortmdm 10 amange for the cremation of the remains and to direct the disposition of the
cremated remains.that any personal possessions have elt her been removed or may be destroyed.and agree to prolect,defend and
save harmless Pine View Crematorium
by connected with thacremation of add remainsas drecte I whetter such claims or demands are or are not wholly
0 t —6�/
(wrtr>ess) )
( Address of Relative egal Representative)
Signed on this date: /
Disposition of Cremated Remains
I hereby direct Pine View Cremetorium to dispose of the cremated renalns as follows:
Mail to
Other arrangements-Please specify:
if pulverization of cremated remains is requested,check here
Revision:April 18,2007