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Smith, Naomi � a '71MN OF- QUEE BU y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSgURY NEW Y.ORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director (3N�E�. Name_ NGp� 1 CNIK A Case # 410 Date of Cremation fUo����� I Z&�S Time Cremation Started $: qb Ah Time Cremation Completed 10 LiS Type of ContainerM �� �cl�u,� Cf zA u4o;.0 Remarks ; M A IN q- S'� �M LA R. 10 9:to b�10 i i - i i 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 aurtartws Pine View Crematorium,in accordance with and subject to its Rules and ReguletIons to CFSnVaie th771, r � rTr( (sex) (Street) (City) State) (ZIP Code) who died on day of ©� 20 O 9 Place) (Address address of nearest relative or nerve ofperson aeon: (Name) Relationship to the deceased Name of Furrerai Home I •`J IMPORTAW: daMrilator,battery.battery Pam,imr I represent that to the best of My Clive ,ft�or her body.(�One) W, cell,radloective imP�rt or I ce*that 1 have full power and Owwrixalion 10 avenge for the cramaiion of the remains and to direct> P of the robaM end and arenrated remains,drat any p��p �lee eMm been removed or may be desboyedk and save haonlew Pine View Cie RNUk nr ftm ate and a/cleirrs and derrrends for loss or dernepes which mybe made agairnst own by reason d or connected with"clan lion d said remains es drecled.rineMnar snCln claims or demands are or are not wholy tweeorkauduMIL JT13ti � (g��and LWIM11elative Legal Represendathre) Signed on this dais: () 3 i [0 Disposlfibn of Ctetneted Remains v, �. tneins as follows:. I direct Pine View Crematorium to dispose of thedxetnet�d re" Mail to Other arrangements-.Pledse specify: if pufy ^!of cremated remains is requested.Check here Revision:April 18,2007