Dubret, Joyce r7n
r � F. QUEE U�I'�/'
IIYE SEW CEMETERY AND CREMATORIUM QUA (F_R ROAD, QUEENSBURY, NEW PORK 12804
(518) 745-4476 (518) 745-4477
_ Funeral Dire-10 ctor �� �
Name J� u
Case a � I
Date of Cremation rr11 ( ��
Nuv"A IQar w
Time Cremation Started
30
Time Cremation Completed
.50
Type of Container CPA UFURd� C
Remarks ; L T r
CoG :3 0
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
cremate the remains of:
J(Name) (SOX)
(Street) (CtiY) (State) (Zip Code)
who died on {1 day of �,)k-)q P.r -\ber zap / Z,�d
at Ll r t
(Place) j(Adder)
Name and address of rest living relative or name of person cremation:
(Name �(Address)
Relationship to the deceased
Name of Funeral Home M O..0 r N 0-n-CA 60- U r F 1
IMPORTANT:
I represent that to the best of my Ivtourledge,the deceased(has)oris no) aker,defibrillator,bettery,battery pack.power
cell,radioactive implant or radioactive device in his or her body.( '
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 nave either been removed or may be destroyed,and agree to protect,defend and
save harmless Pare View Crematorium from arty and all dams and demands for toss or damages which may be made against them
by with the cremation of said remains as dkeded,whether such claims or demands are or are not wholly
ground Ise or
'jgignature and Address of / or Legal Representative)
signed on this date-
Disposition
L
Disposition of Cremated Remains
I hereby direct 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:January 1,2009