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Trackey, Carrie
t ' i �v Off. ` EE BU-9�y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY NEW Y.ORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director Nam Case # Date of Cremation /0 Time Cremation Started '1.. '&)A M Time Cremation Completed Q�� J Type of Container Jr Remarks ; J 0 60 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 W dersig ed requests and eutiUtm Pine View gym,in accordance with and subject to Its Rules and Regulations to cremate the f he remains o 1p M1 I (Name) (sex) 53 P I a:4 S* . 01Y 1 Zvi l 1 ( ) (City) (State) (Zip Code) who died on `'� day of lYAntaer 20L& (—a<� dQ �"M© i�� 1 1� P " (Address) Name and address of nearest Wing relative or name of person au8torift cremation: -ilenn arc k� sk I (Jh►1-c , Avg (Name) (Address) Relationship to the deceased- Name of Funeral Home�A0,Af)c/\X-�>_ 1[Q r x n' I IMPORTANT: I represent dug to the heat of my WvMedge,the deceesed"Maa)_�g�pacemaker,deflbrastor,battery.battery pack,power dio cell,radioactive Implant or reective device in his or her body.( ) I certify that I have U power and aWortmdm to arrange for the cremation of the remains and to direct the disposition of the cremated remains,that any personnel possessions have either been removed or may be destroyed.and agree to protect,defend and save harmless Pine View Crematorium frvm arty 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,faLae or fraudulent. (1Ktrress) (Address) o L (Signat<xe and Aftess of Relative or LegalRepresentative) Signed on this date: J0 N 'y q Disposition of Cremated Remains I hereby dlrW Pine View Crematorium to dispose of the cremated remains as follows: Mail to Other arrangements-Please specify: If pulverization of cremated remains is requested,check here Revision:April 18,2007