Davis, Susan OF. QUEEN
(7 _,5BU9KY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW Y.ORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director �ctW�t-
Name JusCA Q,usc Case
Date of Cremation SCN'f�n l 3 , 200�'j
Time Cremation Started Ph
Time Cremation Completed 3 ZU PM
Type of Container H. Liirdwr'PO , G r Y' 5eic Y. o L
Remarks :
M A 2J 1�� 2 �' P D`1 Nio�� Z'o s 'h
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Town of Queensbury
pine View Cemetery and Crematorium
21 Quaker Road,Queensbuty,New York, 12804
Cemetery Office:(518)745-4476,Crematorium: (518)745-4477
Authorization to Cremate
The undersigned requests and au0ionzes Pine view Crematorium,in accordance witty and S*00 to its Rules and Regulations to
the remains at (�
(name) (Set*
3/( G� 5y 4A) air 13-Uzlf
(Str ) (qly) (State) (Zip Code)
who died on / g� daft of SE-PT 20
at 3 11 ,N�-y ��✓ 6) /V`9
(Place) (Addrew)
Nome and of nearest relative or name of person audKxW hq crerrhetto r
�A�
O (Address)
Rdationshtp b the deceased ��/i
Name of Funeral Flo Q p
IMPORTANT:
I rapnrwernt that to the hest of my Iuhowladge,the deceased(has)a no oarrrelcer,dailbrIator or arty otther herbert►operated
device In this or her body. (C lyde One)
I certify that I have fdt power end authorb allon to arrange for the cremation of the rennafths and to d rec the disposition of the
cremated rernafis,that arts►pen"W po"amions have etcher been rerrwved or may be destroyed,and agree to protect,defend and
save twindess Pine View Creahetorhrrn from any and ad dolma and demands for loss or darrhepes wtrich may be made a ahem
by reason of ar w1h the crenhetion of said remeMs as directed,whadar such dams or dennends are or are not wholy
false freudule�Q.
( )
(Signwture and Address of R—e—W—m-0—rIeW Reps)
Signed on this data )
Disposition of Cremated Remains
I hereby dared Pope View Cremamriurn to dispose of the aernated r6nak*as fdlwrs:
Mail to
Other ar►angemerft-Pleese specify: / -
If pulve bode►of cremated remains is requested.c►edc here
Revrsron..lanuary 1,2006