Deuval, William Jr. OF.. QUEEN5BUr: y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW Y.ORK 12844
(518) 745-4476 (518) 745-4477
Funeral Director_
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Case # 11ar
Date of Cremation_ Zpbc(" 1% . Z065
Time Cremation Started 1. 0T. �r7
Time Cremation Completed 3' 1T
Type of Container `t.�
Remarks ;
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look 3:�S Fah
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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 authortzes Pine View Crematorium,in accordance with and subject to Its Rules and Regulations to
cremate the remain of:
A CA
(Name) `(Sexy)
( ) (may) (State) (Zia Code)
who died on _ Zfp day d 0ct 2C
(Place) ( )
Name and address of nearest Wing relative or name of person authorizing cremation:
, ► I , a 1bV,r-q- l Sid
(Name) (Address)
Relationship to the deceased 12al Q—rr— o
Name of Funeral Hm oe�r'-P A - r +—i � C�i �rY1 r
IMPORTANT:
I represent that to the best of my iorowledge,the deceased(has)or alder,dellbrillator,battery,battery peck,power
cell,radioactive implant or radioedive device in his or her body.(Circle ne)
I certify that I have full power and autiroriz MW 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 prated,defend and
save harmless Pore View Crematorium from any and all claims and demands for loss or damages which may be made agetnst them
by reason of or connected with the cremation d said remains as dtected,whether such claims or demands are or are not wholly
gnxxdieeg,fats or frecdu '
((( (Witness) (Address)
V, - u
`{V (Signaaxe and Address of eWve or Lege1 Representative)
Signed on this date:_ lea l 'O q
Disposition of Cremated Remains
I hereby direct Pine Vim Crematorium to dispose of the cremated remains as follows.
Map to
Other arrangements-Please specify: ry-_(t a-W 4D h
If puNeriza m of aremated remains is requested,check here X
Revision:April 18,2007