Hendricks, Jaqueline z�o o .
F
P QUEENs�
'E V'EW CEMETERY AND
QUAKER ROAD CREMATORIUM
QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Name C;u
Funeral Director&LZA
C -�f�� � _
Case #
Date of Cremation
Time Cremation Started
Time �v
Cremation Completed C0 �I
Type of Container
Remarks ;
rj "
OUR
1��
3A
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
cre a the remaWins of:
(Sex)
�r , h-�/- IZ�ff
(Street) / (City) (State) Rip Code)
who died on I day of ,ram 9
(Place) (Address)
Ne a and address of nearest living relative or name of person authorizing cremation:
33j4-4�1e-�4 W-
(Na // � //(Address)
Relationship to the deceased(44-1 -�
Name of Funeral Home r'1��hora./ •L•��ll
IMPORTANT:
I represent that to the best of my Mowiedge,the deceased(has)or(has no)pacemaker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her body.(Circle One)
I certify that I have full power and authorization to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,that any personal possessions have either been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View Crematorium from any and all claims and demands for loss or damages which may be made against them
by reason of or connected with the cremation of said remains as directed,whether such claims or demands are or are not wholly
groundless,false or fraudulent.
1-� dam _� ./I � 12,F&
_ ( ) (Address)
/"•aszr-3������67�
(SkohikKe and Address of
Relative or Legal Representative)
Signed on this date
Disposition of Cremated Remains
I hereby I P rl Pine View Crematorium to dispose of the cremated remains as follows:
Mal to
Other arrangements-Please specify:
If pin of cremated remains is requested,check here
perloion:January 1.20M