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James, Mary (71-1,7+ OF.- QUEEM,5BU-0�y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW Y.ORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director Name Case # Date of Cremation 7 Q Time Cremation Started_ ' ! Time Cremation Completed ao t Type of Container ( ASr v Remarks : MAIN AArt V- � - 9 ; 5© � I ., oc)L r(; 70 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 aulhortm Pine View CremMtorkRn,in accordance with and subject to Its Rules and Regulations to crenate the ins of: (NMme) M k) _ �r t7.s r� 5�-- ��,.v,�i�.1 <� ZS tr" .S o 3 �? (Street) (City) _ (fie) (23p Code) who died on daY of �_ 20 U 7 at 2� _'S !� (place) (A ) i Name and address of nearest wing retative or rtae of person authoriring cremation: � CQ1,10 A'(— (A s) , �/ w�� Rela�to the deceased `Z 0 _ Name of Funeral Horne /7� R9 LLB L ti1Q IMPORTANT: I represent that to fhe best d my knowledge,the deceased(has (has rro deer.de<ibr�elor,battery.battery f�+poweroell,radioactive implant or nKka ive device in his or her body.( ) I certify that I have 6A power and Ug horiz om to arm mp for the cremation d tha remains and to direct the disposkion of the crenated remai m that any pmonal possessions have either been renored or may be destroyed.and agree to protect,defend and save harmless Pine View Cramet xjurn*am any and eN dsin+s and demands for loss or damages which maybe made agWrat ahem by d or the aanudon of sdd remains as dkecbd.whWw such ddms or demands are or are not wi o (vVitr►ess > • t/t)vr and Address of R / or legal Representative) on this date. [ 9 Disposition of Cremated Remains I hereby direct Pine View Crematorkim to dispose of fhe cremated remains as follows: Mail to Other arrarWmerds-Please speclty: If pAverimion of cremated remains is requested,check here Revision:April 18,2007