Bluege, Howard �o 7+N OF.. QUEEVBU-r�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW Y.ORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name doiv Ul I�tI f-11111111,/ Case # 3oj
Date of Cremation s�, lU 7
Time Cremation Started
Time Cremation Completed
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Type of Container ( 4�cLboa C
Remarks :
MAIN
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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 autrorfzes Pine View Crematorium,in accordance with and subject to Its Rules and Regulations to
cremate the remains of:
I-�C�cy�a�� (9 13iU�GE helms
A77)
iurb Sr aky-s rlls At
(Str") (City) (sue) VIP fie)
who died on day of Sao 7 20a_q
ad 1-71 �uyti �'r �'i~ptis �l�s y �2C-0 /
(Place) O -
Name and address of nearest Koine relative or name of person authorizing cremation: .
O O
Reletlonstilp to the deceased S
Nam d Funeral Florae Ag If
IMPORTANT:
1 represent that to the bast of my Ivwwledge.the deceased(has)or(has no)pacemaker,deftlistor,battery,battery Peck.Power
cep,radioactive imps or radioactive device in his or her body.(Mole One)
f owilly that 1 theme full power mid authorization to arnmW for the cremation d the remains and to dkect the diction d the
cremated remakha,that arty g m i. P i possessions ton either basin removed or maybe destroye4 and agree to prutact,detsird and
saner harmless Pine View Crematorhae from any and aft ofsims and dernerhds for toss or I a 1 which may be made against them
by reeson d or emitted with fhe cremation d said remakhsi as drectsid.+Mhether such Bairns or demands are ar are not who*
groundless,false or taudulent.
(Address)
75
(S ipiature and(Address of Irve
or Legal Repr tve)
Sigrid on this dale: 8 A UePr acre/
Disposition of Cremated Remains
I hereby direct Pine View Crematodum to dispose of the cremated remains as follows:
Mall to
Other snangements-Please sPS(W.
If pulverization d cremated remains is requested.check here
Revision:January 1.2009