Christie, Thomas 0� OF- QUEE B U
-r�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW Y.ORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director �r (
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Name_ � 'l��S'I� Case # 1I
Date of Cremation be -6,-,- 1 � Z��
Time Cremation Started q.14 0
Time Cremation Completed IZI1S P�
Type of Container �i,; L
t.%pJT
Remarks ;
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12 �d�
Town of Queensbury
Pine View Cemetery and Crematodum
21 Quaker Road,Queenobury, New York, 12804
Cemetery Office: (518)7454476, Cr matodum: (518)7454477 '
Aautttori moon to Cremate
The unclerstaned requests and MOVIItes Pone View Crematorkma,in amwdemoe vi th Arad U#od to Its Rubs and Reguldatbns to
crenwe the rem of:
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(Nam)
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(Street) f (Cly) (;ate) (Zip Code)
vwtao died on 80— �—1-L' day of
at H1DVhC_
(Placo) (Addmn)
fYatrne and address d awean�st thrhp arstnthre or rartte of tit autt>Qrtr*3rwg aerrwaikxa:
) (Aftm)
Reietior>sW 10 the deceased Ac
Norse d rowal Home Cu (Y � �w► v«L f]Uwtn� r C
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IMPORTANT:
I represent Mot to the beet of my kwvwieclga,the ftmo rd thee)or(flee no)pec omakw,MWk%w.belt y,battery Peck,Power
call,radioactive WWW or radioacOve le ba M his or her body.(Ckdo One)
I ow*that I hove*0 power and wAhcxtastlon ID ea nMW for this awfoo on of the rewFm*ws and to dkw the dlepoe"m of the
owneted rer wkw that Wq peraoneil poseesaionts have ether been removed or may be dashvyed,and agree to prolect.de kod end
snare hon tens Pkw View Crenrelaium frt m tray and all c ob v and dwnwxb fior loos or damages whlch may be muds against them
by reesvn of o►oortnerfrd wNh ties cronmdon r4 said romeina ea dir+ected.whether such tlirrnt or donaf x%are or are rat wholy
Woo or koxift t.
O
lades of Retst w or Legal Revogentathe)
SWvsd on this date: (0(1 I (0y
Dbpoakbn of Oemsted Ran*"
I hereby dkea Pkwe View Crernal ork m to dispoae of the aremeted ran ro as foNoww.
Masi to
other arrangemenea,Please apadlry:
ff pulve4t atlon d owiatad mffwka Is requested,eiv&here
Revisiom April 18,2007