Bailey, Dorothy PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW Y.ORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director_ tT.114P
Name -1 (
`` Case #
Date of Cremation
Time Cremation Started
Time Cremation Completed <<:bo
Type of Container 4 11� ' Clict � C In1— i S�
Remarks :
IU:OS'
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:
Dorothy Bailey Female
(Name) (Sex)
1116 Lower Maple Hudson Falls, NY 12839
(Street) (City) (State) (Zip Code)
whodiedon 29th dayof October 20 09
at her home
(place) (Address)
and add of living relative or na of ^a ng
(Na ) C� (Address)
Relationship to the deceased
Name of Funeral Home M.B. Kilmer Funeral Home
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or no) er,defibrillator or any other battery operated
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 possessioris have either been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View Crematorium from any and all daims 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
gro false or fraudulent.
J\ (witness) (Address)
(Signa1ure and Address of Relative or egaI Representative)
Signed on this date:
Disposition of Cremated Remains
1 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 1,2006